Ethical decision-making levels of oncology nurses

Abstract

Aim:

This study was carried out in order to determine ethical decision-making levels of oncology nurses.

Ethical Consideration:

Research Ethics Committee's approval was obtained prior to the data collection. Permission to use the Turkish version of the Nursing Dilemma Test was received from Birgül Cerit. Written approval was taken from school administrators to conduct the study confirming that there were no invasive procedures planned for human beings during the study period. The study was conducted in accordance with the Helsinki Declaration. Verbal consent was obtained from each of the nurses who agreed to participate after they were informed about the study content.

Method:

The population of this study conducted in a descriptive way consisted of a total of 96 nurses working at the oncology units and outpatient chemotherapy units of four different hospitals between September 2017 and March 2018. The study sample included 60 nurses who responded to the question form. The data of the study were collected using “Nurses Information Questionnaire” and “Nursing Dilemma Test” developed by Crisham in 1981.

Results:

Oncology nurses’ mean scores in Principled Thinking (49.00 ± 6.46) and those in Practical Considerations (18.35 ± 4.47) were found to be above the moderate level. It was determined that the oncology nurses participated in the study were familiar with situations similar to the dilemmas included in the Nursing Dilemma Test (15.00 ± 4.20).

Conclusion:

It was concluded that oncology nurses try to take ethical principles into consideration but are also affected by environmental factors while making decisions concerning ethical dilemmas. The most frequently encountered ethical dilemmas by oncology nurses include the following: deciding not to perform cardiopulmonary resuscitation, telling the truth to the patient, studies being carried out without the patient’s content, and patient’s refusal of treatment. In order to improve oncology nurses’ critical thinking and ethical decision-making skills, it is important to determine ethical dilemmas encountered by oncology nurses, and nurses should be encouraged to be involved in ethical decision-making process through cooperation with the other healthcare personnel.

Keywords

Clinical ethics ethical decision-making ethical dilemma nursing oncology nurses topic areas

Introduction

By its nature, nursing mainly differs from other professions in that there are several cases that one can encounter in terms of clinical ethics and ethical dilemmas because of the difficulty in choosing the ethical principles to be followed and at the stage of decision-making.¹ Therefore, it is extremely important for nurses to be aware of ethical issues and to provide proper moral justifications and approaches to these problems, and they should develop their ethical decision-making skills.² Ethical decision-making is defined as a reasoning process which involves deciding on the most morally correct action through systematic thinking according to ethical principles when the options are in conflict with one another.³ Decision-making involves the stages of knowing the problem, defining the problem, evaluating alternatives, and choosing best alternative among others. Ethical decision-making is a rational process involving cognitive activity which also includes justification of the ethical judgment and decision.²

In this respect, oncology nurses encounter many ethical dilemmas and problems when making decisions on daily applications such as providing care because of the complicated needs of patients.^4,5 The roles and responsibilities of oncology nurses include ensuring control of the symptoms ranging from outpatient treatment to long-term care, making evaluations of the patient receiving chemotherapy and radiotherapy, providing supportive care and information that the patients and the family need, organizing the care in the treatment of cancer to relieve the patient’s pain, being honest to patients, and helping the patient significantly to make them feel good and recover and reach the specified goals during the treatment process. They have to carry out their professional practices to this end in accordance with the laws and regulations and their own value systems, professional ethical norms, and codes.^6,7 In Turkey, Code of Ethics specified by International Council of Nurses (ICN) is accepted without any change. Previous studies showed that cultural values can influence individuals’ beliefs, ethical decisions, and professionalism. Turkish culture is highly patriarchal and collectivistic. Islam is the main religion in Turkey and emphasizes the sanctity of life. Patriarchal Turkish culture affects nursing care quality and nurses’ professional behaviors in shaping the hierarchical structure in hospitals where physicians are dominant in decision-making. Besides, nurses are also supposed to perform the tasks and directions given by doctors. Informing the patient about the disease is not among the legal obligations of nurses, and in Turkey, nurses are not legally responsible for providing answers to the questions about the diagnosis or situation of a terminally ill patient.²

Previous studies report that oncology nurses encounter ethical problems more frequently.^8
–10 Ethical dilemmas faced by oncology nurses include resuscitation state of the patient,11 futile treatment,^11,12 not telling the truth,^11,12 die in dignity,¹¹ conflicting values in pain management,^9
–11,13 use of resources,^9
–11 informed consent,^9
–11,13 decision-making at the end-of-life care,^9
–11,13 and giving bad news.¹³ It was found that the possibility to face ethical problems such as conflicting values when making decisions concerning the use of sources, informed consent, and end-of-life is higher for oncology nurses compared to other nurses in different fields.¹⁴ In order to overcome these ethical dilemmas, they need to have decision-making skills in ethical issues.¹⁵ However, it was found in a study carried out in the field that the nurses’ level of decision-making about the ethical problems that nurses encounter in clinical settings is not at the desired level.

In conclusion, knowledge of ethical problems and ethical dilemmas is a basic skill required for nurses to make ethical decisions.¹⁶ Timely and right ethical decisions of nurses may help the patient to recover and reduce healthcare costs, whereas inappropriate and ill-timed decisions may cause delay in patient’s recovery and decrease the quality of healthcare services as well.¹⁷ For this reason, oncology nurses must have ethical knowledge and skills as much as their professional knowledge and skills. Therefore, with an ethical approach, nurses would no doubt make significant contributions to the maintenance of a better care for cancer patients.¹⁸

In this regard, this study was planned in order to determine ethical decision-making levels of nurses working at oncology units.

Methods

Data Collection

This study was conducted in a descriptive cross-sectional design. The population of the study consisted of 96 nurses working at two oncology clinics at Ministry of Health affiliated hospitals and two oncology clinics at university hospitals in İzmir, which are the biggest oncology clinics in İzmir, the third largest city in Turkey. Nurses in the study sample were volunteers working in oncology clinics. Since we intended to reach all nurses working at the related hospitals in the survey, no further sampling was used in our study. Because of excuses like illness and unwillingness, 36 nurses were excluded from the study and so the sample of the study consisted of 60 participants (62.5%).

Ethical Consideration

Research Ethics Committee’s approval was obtained prior to the data collection. Permission to use the Turkish version of the Nursing Dilemma Test was received from Birgül Cerit. Written approval was taken from school administrators to conduct the study confirming that there were no invasive procedures planned for human beings during the study period. The study was conducted in accordance with the Helsinki Declaration. Verbal consent was obtained from each of the nurses who agreed to participate after they were informed about the study content.

Instruments

Nurses Information Questionnaire

The questionnaire composed of six questions on the socio-demographic characteristics of the nurses, such as age, educational level, work experience, and work experience in oncology clinic, and six questions about ethics and ethical dilemmas.

Nursing Dilemma Test

Nursing Dilemma Test was developed by Patricia Crisham in 1981. Validation and reliability study of the Turkish version of the test was carried out by Cerit in 2010. Six scenarios are formulated in the test; each presenting a situation intended to generate moral confusion for nurses providing care to the patient and family. These ethical dilemmas include the following: (a) newborn with anomalies considering the definition and promotion of quality of life, (b) forcing medication, (c) adults’ requests to die, (d) orientation of a new nurse, (e) medication errors, and (f) terminally ill adults. Each the ethical dilemma involves three sections. The first section is about the necessary actions needed to be taken in the ethical dilemma presented in the scenario and nurses are asked to mark one of the three options provided for each ethical dilemma. The second section presents six statements about their attitudes toward to the scenario related to the ethical dilemma. Nurses are asked to choose the most important one among these six statements and to rank them according to their importance. Responses given in this section of the test are intended to determine the levels of “Principled Thinking” (PT) and “Practical Consideration” (PC). The possible minimum PT score on the test is 18, the maximum PT score being 66. The lowest PC score that could be obtained on the test is 6 while the highest PC score is 36. PT indicates how important it is to consider moral principles when making a moral decision in nursing. However, PC measures the importance attached to such environmental factors as the number of patients, the quantity of resources available, institutional policies, nurses’ degree perception of the support provided by the administration, and the doctor’s control when making decisions about ethical problems. In the third section, nurses are asked about their past experience with a similar dilemma. Nurses’ state of having experience with a similar dilemma was evaluated depending on the answers given in this section, and the “Familiarity” score was obtained on a Likert-type scale. A Familiarity score of 6–17 indicates participants’ familiarity with a similar dilemma, whereas a score of 18–30 shows no familiarity with a similar dilemma.³

Statistical analysis

Statistical analysis was performed using SPSS (version 17.0, SPSS Inc, Chicago, IL, USA). Descriptive analysis was used to analyze general subject characteristics through frequency, percentage, and means. Categorical variables were tested with Student’s t-test considering p < 0.5 as statistically significant.

Results

Table 1 shows descriptive features of the nurses. Mean age of the nurses was found as 34.18 ± 6.72 years, and almost all of them (98.3%) were female. A great majority of the nurses (80%) have a Bachelor of Science degree. One-third of them (28.3%) have previous experience of ethical dilemma in their working life, and the greatest ethical dilemma is about the decision not to perform cardiopulmonary resuscitation (CPR; 47.1%; Table 1). As a result of the evaluation of the data obtained from the second section of the Nursing Dilemma Test, mean PT, PC, and Familiarity scores that oncology nurses could get over this test were calculated. It was found that the mean PT score 49.00 ± 6.46 (min: 30–max: 63) was slightly higher than the average, whereas the mean PC score 18.35 ± 4.47 (min: 10–max: 28) was close to the average. The mean Familiarity score was 15.00 ± 4.20 (min: 6–max: 24), indicating that nurses were familiar with similar dilemmas (Table 2).

Table 1.

Descriptive features of oncology nurses (n = 60).

Descriptive features	n	%
Mean age, years	34.18 ± 6.72 (22–51)
Mean years of working experience	11.13 ± 7.36
Mean years of oncology nursing experience	5.40 ± 4.39
Sex
Male	1	1.7
Female	59	98.3
Educational level
Associate degree	5	8.3
Bachelor of Science degree	48	80.0
Master Science/PhD	7	11.7
Ethical dilemma during clinical experience
Yes	17	28.3
No	43	71.7
Ethical dilemmas experienced^a
Deciding not to perform CPR	8	47.1
Not telling the truth to the patient	3	17.7
Do research without the patient’s consent	2	11.7
Giving the medication forcefully	2	11.7
Conflict with institutional rules	1	5.9
Conflict with doctor’s order	1	5.9
Total

CPR: cardiopulmonary resuscitation.

^a Percentages have been calculated based on 17 respondents.

Table 2.

Mean scores of oncology nurses levels of ethical decision-making in Nursing Dilemma Test (n = 60).

Nursing Dilemma Test	M (SD)	Minimum	Maximum
Principled Thinking	49.00 ± 6.46	30	63
Practical Consideration	18.35 ± 4.47	10	28
Familiarity	15.00 ± 4.20	6	24

The data obtained from section A for each scenario of Nursing Dilemma Test, 38.3% of the nurses were in favor of resuscitation of a newborn with abnormalities, more than half (58.3%) supported administering medication against the will of the patient while, and 21.7% of them remained undecided. In the third scenario, 86.7% of the nurses stated that they would provide respiratory support despite the request of a competent adult patient to die. Approximately, half the nurses (51.7%) think that time for the orientation of new nurses into the pediatric nursing clinic is sufficient. Most of the nurses (80%) stated that medication errors should be informed. In the last of the scenarios, a dilemma was presented about a terminally ill adult asking about his diagnosis in spite of his doctors’ and family members’ will. In total, 40% of the nurses think they must answer patients’ questions while 25% remained undecided (Table 3).

Table 3.

The distribution of oncology nurse’s responses to “What should the nurse do?” question in each ethical dilemma of the Nursing Dilemma Test (n = 60).

Dilemmas	“What should the nurse do?”	n	%
Newborn with anomalies	Should resuscitate the newborn	23	38.3
	Undecided	17	28.3
	Should not resuscitate the newborn	20	33.3
Forcing medication	Should forcefully give the medication	35	58.3
	Undecided	13	21.7
	Should not forcefully give the medication	12	20.0
Adult’s request to die	Should provide assistance for artificial respiration	52	86.7
	Undecided	5	8.3
	Should not provide assistance for artificial respiration	3	5.0
New nurse orientation	Should allocate time for orientation of the nurse	31	51.7
	Undecided	13	21.7
	Should not allocate time for orientation of the nurse	16	26.7
Medication error	Should report the medication error now	48	80.0
	Undecided	9	15.0
	Should not report the medication error now	3	5.0
Terminally ill adults	Should answer the patient’s questions	24	40.0
	Undecided	21	35.0
	Should not answer the patient’s questions	15	25.0

Discussion

In this study, most frequently encountered ethical problems by nurses are as follows: deciding not to perform CPR, telling the truth to the patient, carrying out studies without informed consent of the patient, and refusal of treatment by the patient, and this shows similarity with the results of the previous studies reviewed in the literature.^9

–13

The evaluation of the responses made by oncology nurses to the scenarios in the scale shows that nurses ignore the principle of autonomy and beneficence when making decisions in all scenarios and that they support life under any condition instead of respecting patient autonomy and increasing quality of life (Table 3). As far as these results are concerned, it can be stated that nurses adopt a paternalist viewpoint. Libertarianism, on the contrary, highlights the significance of individualistic role when making decisions and seeking for freedom of choice and maximum autonomy.¹⁹ Studies with nurses have revealed that nurses tend to act on their behalves to assert the patient’s rights and they choose traditional behavior when making ethical decisions rather than employing autonomy.^3,19,20 The common problem of all nurses providing end-of-life care is to maintain a balance between extending life, times of patients, and improving their quality of life. Trying to attain this balance inevitably causes moral conflicts. Many nurses fail to offer ideal nursing care at end of life because they feel weakness and burnout in the face of caring a terminally ill patient and death.²¹ Decision-making particularly in end-of-life care continues to be a controversial issue which differs by the legislation in each country. Most of the time, healthcare personnel involve patients’ relatives who know them well in the decision-making process based on the principle of avoiding damage in critical decisions like withholding or withdrawing treatment. The most significant point in this process is whether the decision made is in compliance with the patient’s will or not and whether it will consider the patient’s quality of life in the future. Studies report that the process of withdrawing treatment is associated with the decision-makers’ skills, value judgments, personal preferences, and the established culture of the institution.²² Therefore, nurses and all healthcare professionals are expected to have competent knowledge and skills concerning ethical decision-making process in order to make the most accurate decision on behalf of the patient.

Telling the truth about diagnosis and prognosis to terminal-stage cancer patients is a controversial universal ethical problem. Explanation of the terminal disease differs from culture to culture. In Western countries, healthcare professionals usually explain the diagnosis to cancer patients directly by taking patient autonomy into consideration. In Eastern countries, however, most specialists adopt a traditional attitude and abide by the family’s decision. According to the International Committee of Nurses (ICN) Code of Ethics, in order to avoid mistakes in nursing interventions, nurses are expected to provide sufficient information about nursing interventions to patients and to act in accuracy and fairness to protect the rights of patients under any conditions.²³ Code of Ethics specified by ICN is accepted without any change in Turkey. In Turkey, nurses are also supposed to perform the tasks given by doctors. Informing the patient about the disease is not included among the legal obligations of nurses and nurses are not officially responsible for answering questions about the diagnosis or situation of a terminally ill patient in Turkey. All these restrictions could make nurses feel that they cannot make their ethical decisions on their own when faced with ethical dilemmas because of the environmental conditions or their professional and official responsibilities.²

Studies show that nurses’ ethical decisions made at the right times are effective in patient recovery, reducing healthcare costs, and improving the quality of healthcare services.¹² Since the number of studies conducted on ethical decision-making levels of oncology nurses is limited, the results presented by previous studies on ethical decision-making levels of oncology nurses were used when evaluating the data obtained from this study. In addition, some studies state that nurses fail to take adequate advantage of ethical principles when making decisions and that they do not have the expected level of ethical sensitivity.^24,25

Principled Thinking indicates how much importance is attached to considering moral principles when making an ethical decision in nursing. Mean PT scores of oncology nurses were found to be slightly above the average level in this study (Table 1). Some studies carried out with nurses^2,3,26,27 and nursing students^20,28 reported PT scores above average, which supports our findings. In order to make ethical decisions, it is necessary to have guidance and knowledge of the ethics theory, ethical principles, and practice. If it were not for education on ethics, nurses would act according to environmental factors and their personal sense of ethically correct actions.²⁹ In this regard, oncology nurses’ PT scores can be accepted as desirable levels and it can be stated that they are acting in accordance with the ethical principles rather than environmental factors when they encounter ethical dilemmas. Moreover, this situation is thought to affect ethical decision-making in a desired and positive way.

Practical consideration evaluates how much importance is attached by nurses to environmental factors such as the number of patients, the quantity of available resources, institutional policies, the degree of nurses’ perception of the support given by the administration, and the doctor’s control when making decisions about ethical problems.¹¹ This study found oncology nurses’ mean PC scores close to the average (Table 2). Based on this finding, it can be concluded that nurses are relatively influenced by factors when making decisions concerning the solutions of ethical dilemmas. Most of the time, nurses feel the pressure because of such environmental factors as hospital policies conflicting with their personal values, obedience with the doctor’s order, time limitation, uncertainties concerning professional authorities and responsibilities, and different expectations from patients, administrators, and colleagues. Therefore, when reflecting their values, life experiences, ethical sensitivity, and reasoning ability on the process of ethical decision-making and acting accordingly, nurses are affected by many environmental factors.²⁶ Mean PC scores found in this study are parallel to those obtained in the previous studies.^2,26

Nurses can discuss an ethical problem they encounter, generate suitable solutions, and make ethical decisions with the help of familiarity. When nurses are unfamiliar with ethical dilemmas, it becomes difficult to make ethical decisions and may cause the nurse to employ practical thinking.³ In our study, oncology nurses’ mean Familiarity score was 15.00 ± 4.20, showing that they were familiar with similar ethical dilemmas (Table 1). In this regard, it could be stated that in their real-life clinical practices, oncology nurses encounter situations similar to those included in the scale. While one study with students supports our findings, studies carried out with nurses reveal that nurses face with similar dilemmas more frequently in their clinical practices.^2,30 However, it should not be ignored that familiarity with ethical dilemmas and related knowledge are not enough for an effective ethical decision-making process and solution of dilemmas.³ According to the literature, knowledge gained through ethics education plays an important role in acquiring necessary skills to cope with ethical problems and to participate actively in the decision-making process in addition to its positive effects through internalization and integration by the member of profession with their own experiences.^2,20

Limitations of the study

The findings of this study need to be considered in the light of some limitations. First, the study was conducted with a small number of oncology nurses, and thus, generalization of the results to oncology nurses in this country is weak. Second, because there is only one scale on ethical decision-making level of nurses which has been tested for validity and reliability in this country, findings on the topic were obtained in the study using one scale. Finally, nurses’ attitudes toward basic ethical principles, especially autonomy and utility, should be assessed by with detailed questionnaire in the future studies.

Conclusion and implications for nursing practice

As a result of the study, it was determined that oncology nurses are familiar with ethical dilemmas and the most frequently encountered dilemmas include the decision not to perform CPR, telling the truth to the patient, carrying out scientific studies without the patient’s consent, and the decision in the case of patient refusal of treatment. In addition, it was found that when making decisions on ethical dilemmas, nurses’ level of considering ethical principles is above the average, and that environmental factors affect their decisions. It was also observed that nurses ignore the principle of autonomy and utility from time to time when making decisions on ethical dilemmas.

In order to improve oncology nurses’ critical thinking and ethical decision-making skills, it is important to determine ethical dilemmas encountered by oncology nurses and develop their levels of ethical decision-making. Moreover, nurses should be encouraged to be involved in ethical decision-making process through cooperation with the other healthcare personnel. Finally, the principle of autonomy and utility must be stressed in the courses on ethics delivered at schools and in-service trainings, and nurses’ knowledge and skills concerning ethical decision-making process should be enhanced and improved.

Footnotes

Acknowledgements

The authors thank all the oncology nurses who participated in this study.

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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