Ethical Conflicts Reported by CertifiedRegistered Rehabilitation Nurses

Barbara K. Redman, PhD RN FAANSara T. Fry, PhD RN FAAN

The purpose of this study was toidentify the types ofethical conflictreported by certified registered reha­bilitation nurses (CRRNs) and theirrelationship to demographic, educa­tional, and practice-setting variables.Ethical conflicts expressed by CRRNsin active practice in Maryland, Vir­ginia, and the District ofColumbiawere analyzed according to fourthemes. Disagreements about medicalor institutional practice, patients'rights, and payment issues were themost frequent practice contexts forethical conflicts, reflectingthese nurs­es' considerable underlying concernsabout resource allocation in rehabil­itation practice. Participants believedthat 60% ofthe ethical conflicts wereresolved, frequently through discus­sions with other team members andpatients' family members. Ethics com­mittees and consultants were used in­frequently. There were no statistical­ly significant relationships betweenthe kinds ofconflicts or their resolu­tion and the participants' demo­graphic, educational, and practice­setting variables.

Address correspondence to BarbaraRedman, PhD RN FAAN, UniversityofConnecticut School ofNursing,231 Glenbrook Road, U-26, Room113, Storrs, CT 06269-2026.

Professionals in every field of practice face a set ofpotentially conflicting ethical is­sues. These conflicts emerge because of professionals' differing ethical beliefs, duties,principles, and theories when each side of the conflict has a morally defensible position(Mitchell, 1990). Because nurses are responsible for providing direct care and advo­cating for their patients but often lack either the personal authority or access to deci­sion-making channels, they are especially vulnerable to experiencing ethical conflicts.If ethical conflicts go unrecognized or unresolved, they can have a serious impact onthe ability of health professionals to deliver adequate care. Conflicts can also have anegative impact on nurses' morale, sometimes being a factor in burnout and decisionsto leave the field (Rodney & Starzomski, 1993).

It therefore behooves those in each field of practice to identify and develop con­structive ways for dealing with commonly experienced ethical conflicts before negativeconsequences become serious. Because what is perceived as an ethical conflict fre­quently differs by discipline, the work of identificationand resolution should be done with­in each of the disciplines directly involved in patient care. This understanding can thenform the basis for interdisciplinary discussions.

Review of the literatureThe most recent comprehensive examination of ethical issues facing the field of re­

habilitation was accomplished a decade ago by the Hastings Center and supported by agrant from the Pew Trust (Caplan, Callahan, & Haas, 1987). The issues that a group ofpractitioners and medical ethicists defined as ethically problematic included informedconsent, truth telling, paternalism, negotiated goals of care, and allocation of scarce re­sources. The following specific ethical issues were identified:

Acceptance ofand termination of treatment: These decisions are said to be madeon subjective grounds, and patients may not know the criteria on which they are madeor may not have recourse to appeal. Do those who are rescued by the acute care systemhave a legitimate claim to receiving follow-up rehabilitative services?

Informed consent: Depression, insufficient knowledge about future possibilities,and a radical alteration in a person's sense of self during an illness can render patientsunable to make autonomous decisions. Should decisions they make under these condi­tions be followed?

Goals of treatment: Whose values-the physician's or the patient's--determine thegoals of treatment? Should patients be persuaded to accept or challenge the limitationsthey might encounter in the community?

Involvement of the family: The usual principle of patient confidentiality is not pos­sible because family members often determine the level of recovery needed for a pa­tient to function as well as the financial and caregiving resources that are available. Fam­ily members may become trapped into accepting a caregiving role they would not choosefreely.

Rehabilitation team: Team members may be viewed as disloyal or unethical if they

Rehabilitation Nursing > Volume 23, Number 4· Jul/Aug 1998 179

Ethical Conflicts

raise issues about the competency of other members or the ad­equacy of the treatment plan.

Resource allocation for rehabilitation: Is it fair that theactual number of people receiving rehabilitation is far belowthe number who might benefit from access to it?

The clinical and policy contexts for the ethical issues facingrehabilitation professionals are quite different from those inacute care medicine. The situation is exacerbated by the factthat those who most often need rehabilitative services are thosewho are already undervalued by society.

At the present time, little attention has been given to an em­pirical study of patient care situations that healthcare providersperceive to be ethical conflicts. We could not locate any suchstudies for a major group of providers-that is, registered nurs­es working in rehabilitation.

Our study of ethical conflicts was guided by a conceptualframework of ethical decision making and was structured bytwo broad theories of ethics, namely utilitarianism (the greatestgood for the most) and deontology (acts are right or wrong),and by the principle-based common morality theories ofbenef­icence, autonomy, nonmaleficence, and justice (Beauchamp &Childress, 1994). Ethics committees in healthcare institutionsuse this conceptual framework to reflect on problematic casesand frequently to consider decisions made in similar cases. Thisapproach to ethical decision making results in one or more rea­soned recommendations about ethical courses of action that canbe followed. Previous study has demonstrated that individualpractitioners use the same kind of reasoning when resolvingethical conflicts in patient care.

Purpose of the studyThe purpose of the study was to identify the types of ethical

conflict that a group of certified registered rehabilitation nurs­es (CRRNs) reported in their practice and to examine the de­mographic, educational, and practice-setting factors associat­ed with these ethical conflicts. This research is meant to be afirst step in studying ethical conflicts in rehabilitation care andin working through methodological issues in the most effectiveways to describe the conflicts.

Moral development theory suggests that age, sex, and for­mal education affect moral reasoning abilities (Rest, 1986).Other researchers suggest that ethics education and the amountof nursing experience also affect the development of nurses'ethical decision-making skills. Because this was an explorato­ry study, we included these variables to suggest direction forfurther research.

Research design and methodsSample selection: We selected CRRNs for this study pop­

ulation to ensure that participants had at least the minimal lev­el of knowledge required to pass the certification examination.All CRRN members of the Association of Rehabilitation Nurs­es (ARN) from Maryland, Virginia, and the District of Colum­bia were contacted and asked to participate in the study. Thesample was accrued in two phases. First, we mailed survey in­struments to all ARN members from these jurisdictions who

180 Rehabilitation Nursing> Volume 23, Number 4· Jul/Aug 1998

were CRRNs and asked them to participate (N = 469). Sevensurvey instruments were returned by the post office, thus re­ducing the sample to 462. Of these, 261 CRRNs (56%) re­sponded. Eligibility requirements for the second phase includ­ed current practice in a rehabilitation setting and an indicationof a willingness to participate by completing the instruments.Eighty-two subjects indicated that they were not currently work­ing in a rehabilitation setting, 63 indicated they did not wish toparticipate, and 14 submitted incomplete instruments. Of the102 who provided completed questionnaires (39% of Phase Irespondents), 4 indicated they had not experienced ethical con­flicts in their practice, and 7 described conflicts that were judgedby the two raters to be organizational rather than ethical in na­ture. The analysis was carried out on the information from theremaining participants (N = 91).

Instruments and data collection: The Demographic DataForm (DDF) is a questionnaire designed to collect vital statis­tics and information about survey respondents' educationalbackground and clinical practice. The Moral Conflict Ques­tionnaire (MCQ), an open-ended questionnaire, was designedto elicit descriptions of ethical conflicts in professionals' prac­tice. Respondents were asked to describe a moral (ethical) con­flict they had experienced in their area of nursing practice andto identify what the conflict was for the rehabilitation nurse.These tools, originally developed and tested for content valid­ity by Fry (1987), have been used in several other studies.

The protocol for our study was approved by the Universityof Connecticut Institutional Review Board, and data were col­lected during the spring and summer of 1996. Participants wereasked not to identify themselves, other staff, patients, or theirinstitutions on the questionnaires. The completion and returnof the questionnaires constituted informed consent.

CRRNs were asked to identify and describea moral conflict they had experienced in

their nursing practice.

Data analysis: We used descriptive statistics to analyze thedata from the DDF. We analyzed each ethical conflict describedon the MCQ according to four content analysis schemes in or­der to capture relevant meanings. The entire conflict served asthe unit of analysis. Categories for ethical conflicts within eachclassification system are mutually exclusive and exhaustive.We both have had education in ethics and independently cod­ed the ethical conflicts within each system. We revised the cod­ings and their definitions until we obtained an interrater agree­ment of 100%. Therefore, we did not compute chance-adjustedagreement rates (i.e., a kappa statistic).

Classification System I, the first content analysis scheme,described the practice context of the conflict. In the absence ofprior studies on this dimension for rehabilitation nurses' ethi­cal conflicts, we constructed this system from the data. Classi­fication System II, the second content analysis scheme, lookedfor the ethical principles and values the nurses used when de­scribing the conflict. These concepts have commonly under-

Table 1. Demographic Characteristics ofParticipants (N =91)

stood meanings (Beauchamp & Childress, 1994). Classifica­tion System III, the third content analysis scheme, character­ized how nurses experienced the conflict by using Jameton's(1984) definitions of moral conflicts in nursing practice. Jame­ton defined three major ways an ethical conflict is experienced:

1. A moral dilemma is experienced when two or more clearmoral principles apply to the conflict situation but they sup­port mutually inconsistent courses of action.

2. Moral distress is experienced when a person knows theright thing to do, but institutional constraints make it near­ly impossible to pursue the right course of action.

3. Moral uncertainty is experienced when a person is unsurewhich ethical principles or values apply or is uncertainabout the nature of the moral problem.

Classification System IV,the fourth content analysis scheme,

Age

SexFemaleMale

Initial nursing preparationAssociate degreeDiplomaBSN

Mean = 42.7 yearsRange = 26-63 years

91%9%

23%22%54%

was guided by categories from prior studies (Butz, Redman,Fry, & Kolodner, in press; Redman, Hill, & Fry, 1997) but wasmainly constructed on the basis of the data obtained from thisstudy. This analysis scheme provides for a description of theresolution of the conflict. Some participants described morethan one ethical conflict, and these data were treated as sepa­rate reported conflicts.

We used chi-square tests and analysis of variance to exam­ine the relationship between the types of ethical conflicts andthe demographic, educational, and practice-setting variables.When participants provided more than one ethical conflict, weused the first one for this analysis.

ResultsDescription of the participants: The demographic char­

acteristics of the participants appear in Table 1. The mean ageof the participants was 43 years, and 91 % were female. A bac­calaureate was the most common initial nursing preparationfor the participants in our study; 82% had either a baccalaure­ate or a master's as their highest academic degree. Approxi­mately 80% had been in their current positions 5 years or more.Approximately 75% of the participants were either nurse man­agers or case managers, most often in hospital-based or free­standing rehabilitation units.

We assessed the participants' exposure to ethics instructionby asking them to indicate whether ethics had been taught bynursing or other faculty and whether ethics-related course con-

Table 2. Classification System I: Context for EthicalConflict (N =119)

% of TotalPayment policies (managed care, insurance) 20%

Highest academic preparationAssociate degree or diplomaBSNMSNorMSOther

Length of time in present positionLess than 5 years5-10 yearsMore than 10 years

Primary area of responsibilityStaff nurseNurse managerCase manager

Practice settingHospital rehabilitation unitFreestanding rehabilitation unitSubacute settingLong-term care facilityOther

10%48%34%

3%

20%34%47%

26%49%26%

30%34%10%8%

32%

Patients' rights issuesConfidentialityFamily issuesCode status, advance directivesTreatment refusals

Disagreement with patients' decisions

Disagreement with medical and!or institutional practiceOvertreatment (terminally ill patients,

futile rehabilitation services)Undertreatment (lack of access,

inequitable treatment)Treatment that does not meet standards of care

Not an ethical dilemma

Not enough data

7%9%3%8%

o

1%

12%

10%

11%

10%

7%

Note. Percentages may not total 100% because of missingdata, multiple choices, or the effects of rounding. Other (institutional downsizing, reorganization) 2%

Rehabilitation Nursing' Volume 23, Number 4' Jul/Aug 1998 181

Ethical Conflicts

Table 3. Classification System II: Principles orValues in Conflict with Other Ethical Principlesor Norms (N =108)

a Beneficence: Moral obligation to do good for othersb Nonmaleficence: Moral obligationnot to inflict evil or

harmC Autonomy: Moral obligationto respect self-determinationd Professional ethics: Moral obligation for safe and effec­

tive care in conflict with duties to maintain the profes­sional relationship

tent was integrated into their programs of study or was provid­ed by specific ethics courses. Participants who reported havinghad multiple educational experiences were considered to havehad more exposure to ethics instruction. Twenty-one percentreported that they had not had any formal instruction in ethicsin their basic nursing programs, 53% reported that they had nothad any formal ethics preparation since their basic nursingpreparation, and 38% reported that they had not had any con­tinuing education in ethics.

Most CRRNs reported having various resources available intheir current work setting to help them resolve ethical conflicts:an ethics committee (53%), ethics consultant (12%), nursingpeers (72%), nurse manager (41%), physician (37%), lawyer(28%), and a professional organization (23%). Only 7% reportedthat they had no resources to help them resolve ethical conflicts.

Description of ethical conflicts: Table 2 presents the clin­ical context for the conflicts described by the participants. Bothraters judged that 10% of the reported conflicts were organiza­tion-related in nature rather than ethical. Those conflicts judgedto be ethical in nature most commonly involved disagreements

Beneficence" vs. nonmaleficence"Autonomy'vs. beneficence"Professionalethics"Legal vs. ethicalprinciplesResourceallocationsNot enough dataOther

% of Total20%23%16%8%

27%3%3%

with medical or institutional practice (34%), patients' rights(28%), and the payment policies of managed care and insur­ance companies (20%).

Of these conflicts, the participants described instances ofovertreatment, undertreatment, or treatment that did not meetthe standard of care. These conflicts focused on patients witha short life expectancy (particularly due to cancer) who werebeing pushed to have rehabilitation to a degree that nurses feltwas abusive. Nurses believed that a hospice was a more appro­priate setting for these patients, and they worried that these pa­tients were being robbed of time to attend to their last wishesduring the last few weeks of their lives. Conflicts regarding pa­tients' rights often involved nurses' perceptions that their ownworkloads were too high to provide effective care to individualpatients. Conflicts regarding payment policies included thosein which managed care case managers restricted services on thebasis of cost and neglected rehabilitation outcomes as well asthose in which patients were discharged before they were phys­ically or mentally ready.

The ethical principles and moral values that the participantsdescribed as being central to the conflict were a fair allocationof resources (27%) and the conflict between beneficence andnonmaleficence (20%) (see Table 3). Most of the reported con­flicts reflected serious concerns about either placing patients inprograms that did not fit their needs or denying them access toneeded services. Nurses believed that some patients who weremaking slow progress and who also had questionable supportsystems were often given only a brief trial stint in rehabilitationbefore being discharged. Twenty-three percent of the reportedconflicts involved a tension between healthcare professionals'perceived obligations to respect patients' autonomy and the pro­vision of beneficent care by the provider. These conflicts in­cluded situations prototypical of the rehabilitation field, for ex­ample, patients who refuse to comply with care that rehabilitationprofessionals view as essential. Some participants believed thatrefusing rehabilitation care was the patient's right (autonomy),whereas others thought that failure to push a patient constitutednegligence on the part of the nurse who was involved.

The participants in our study rarely experienced moral un­certainty (see Table 4). They experienced more than half of theconflicts as moral dilemmas and approximately 40% as moraldistress. Showing consistency with dominant themes, the nurs-

Table 4. Classification System III: How fhe Conflict Is Experienced (N =108)

ClassificationMoral dilemma

Moral distress

Moral uncertainty

Not enough data

DefinitionArises when two or more clear moral principlesapply but they supportmutually

inconsistentcourses of actionArises when a person knows the right thing to do but institutionalconstraintsmake it

nearly impossible- to pursue the right course of action (Nurses may have neither thepersonal authority nor access to the decision-making channels needed to resolve theissue.)

Arises when a person is unsure about which moral principlesor valuesapply or evenabout what the moral problemis

% of Total56%

39%

2%

4%

182 Rehabilitation Nursing' Volume 23, Number 4· Jul/Aug 1998

es who described moral distress felt caught between the poli­cies of insurance companies or physicians' plans of care thatthey believed were inappropriate or did not meet standards andtheir own commitment to their patients' welfare. Participantssaid that the majority (58%) ofthe reported conflicts had beenresolved, most frequently through discussions with the reha­bilitation team or the patient's family (see Table 5). In some in­stances, nurses took action to protect patients from harm by re­porting problems to adult protective services, instituting referralsto make home environments safer, speaking very frankly withthe attending physician, trying to protect the patient's confi­dentiality, or involving the institution's attorney to advocate forinsurance payment. In certain instances, CRRNs encouragedpatients and their families to seek second opinions, or they pro­vided aggressive educational programs for families that taughtthem how to care for the patients. More than one-third of theconflicts remained unresolved, frequently leaving nurses to sim­ply cope with the situations. It is noteworthy that participantsinfrequently used ethics committees or consultants to either dis­cuss or resolve the reported ethical conflicts.

Relationship of ethical conflicts to demographic, educa­tional, and practice-setting variables: We found no signifi­cant relationships between Classification Systems I-IV and thefollowing variables: initial nursing preparation, highest acade­mic degree, length of time in a position, primary area of re­sponsibility, amount of exposure to ethics instruction, practicesetting, and the number ofethics resources available to help re­solve ethical conflicts.

Table 5. Classification System IV: Resolution ofEthical Conflicts (N =108)

% of TotalResolvedDecidedthroughteamor familydiscussion 22%Took actionto protect the patient 15%Educatedthe patientor family to take action 7%Went alongwith other's decision 3%Resolved by the ethicscommittee 6%Other 5%

Not resolvedNurserefusedto go along

Reported the conflictto a supervisor 4%Referredthe conflictto the ethics 2%

committee or a consultantConfronted the physicianor the administration 4%Other 1%

Nursecoped 25%

Nurse removed himself or herself 1%from the situation

Not enough data 5%

Other 1%

DiscussionThis study had several limitations. First, respondents might

not have been representative of the larger population of CRRNsin their states. Also, Classification Systems I and IV,constructedon the basis of the data in this study, may similarly reflect theserespondents' limited experience. Furthermore, the DDF maynot include questions that elicit all of the relevant factors relat­ed to the experience of ethical conflict.

A significant number of the participants reported that dis­agreement with medical or institutional practices provided thecontext for their ethical conflicts. They disagreed with whatthey perceived to be overtreatment of patients, especially treat­ment for terminally ill patients or rehabilitation services for pa­tients who would not measurably benefit from such services.The nurses also disagreed with those who prescribed rehabili­tation services that did not meet the standards of care in thepractice field. The nurses' knowledge about rehabilitation ser­vices and their benefits, in some cases, may have exceeded thatof the physicians prescribing the rehabilitation. This is a con­sistent finding among nurses with advanced specialty educa­tion (Redman & Fry, 1996; Redman et aI., 1997).

The findings of this exploratory study also focus strong at­tention on resource allocation, one of the ethical issues that wasidentified as a problem in the rehabilitation field a decade ago.This conflict is, no doubt, exacerbated by the significant expan­sion of managed care in the past decade. Thus, the strongly util­itarian ideology of managed care is in conflict with the traditionof the provider-definedconcept of beneficence toward individualpatients. Those who support the mechanism of managed care be­lieve that it is capable of restoring trust in the healthcare systemthat was declining in the old fee-for-service system. Those whoare concerned about developing ethical standards say that stan­dards have been slow to develop in the managed care industryand are more likely to be framed in terms of patients' rights thanof caregivers' and institutions' obligations (Gray, 1997).

The majority of the ethical conflicts reported in this studyhad been resolved; this was done primarily by nurse-initiateddiscussions among rehabilitation team members and patientsor their family members. By recognizing ethical conflicts andthen discussing them with other team members and with pa­tients, nurses can avoid serious and prolonged conflicts of val­ues while providing care. This is the desirable course of eventsfor resolving ethicalconflictsin the deliveryof health care. It sup­ports the important role of healthcare providers in promotingquality of care and recognizes that resolution of ethical con­flicts is best made in collaboration with various members of thehealthcare team and patients or their family members or both.

Nursing implicationsFuture studies based on this work should verify the conflicts

reported by this group in a wider sample, identify conflicts in oth­er rehabilitation disciplines, and further develop assessmenttools and educational interventions to help these groups recog­nize and manage such conflicts. Work of this kind is essentialto the development of a database on rehabilitation ethics and tothe burgeoning field of clinical nursing ethics.

Rehabilitation Nursing' Volume 23, Number 4' Jul/Aug 1998 183

Ethical Conflicts

During this time of a major paradigm shift in health care andpayment systems, rehabilitation professionals have a major re­sponsibility for quantifying the outcomes that cost-effective re­habilitation services can yield for patients and society at largeand for advocating for policies that support appropriate ser­vices. Regulation of managed care is proceeding in an effort todevelop fair systems of al1ocation of resources.

Further study is needed to examine how nurses resolve eth­ical conflict and which factors contribute to the resolution ofethical conflicts in the rehabilitation nursing specialty as wel1as in nursing in general. The conditions under which ethicalconflicts remain unresolved and the effects of unresolved con­flicts on the quality of patient care and on the retention of nurs­es in specialized practice settings also require further study.Nurses playa significant role in the safety and quality of patientcare in all practice settings. Rehabilitation nurses serve patientswho are experiencing major alterations in their physical abili­ties. Rehabilitation services may have a significant effect on pa­tients' future abilities to care for themselves and their contin­ued need for costly services. Understanding how ethical conflictsaffect the delivery of rehabilitation services is necessary to im­prove the delivery of these services into the next century.

AcknowledgmentThis research was supported by a grant from the Rehabili­

tation Nursing Foundation of the Association of RehabilitationNurses (ARN). The views herein are those of the authors, andno endorsement by ARN is intended or should be inferred.

This continuing education offering (codenumber RNC-132) will provide 1 con­tact hour to those who read this articleand complete the application form onpage 220.This independent study offering is ap­

propriate for all rehabilitation nurses. By reading this arti­cle, the learner will achieve the fol1owing objectives:

1. Explain how ethical conflicts differ from other kinds of con­flicts experienced in practice.

2. Describe the two most frequent types of ethical conflicts ex­perienced by CRRNs participating in this study.

3. Describe how a rehabilitation nurse might go about resolvingan ethical conflict.

The Certified Rehabilitation Registered Nurse­Advanced program is for nurses who have the CRRNcredential and who practice at the advanced level.

The Certified Rehabilitation Registered Nurseprogram is for rehabilitation nurses with a minimumof 2 years' experience in the specialty.

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For more information, contactRehabilitation Nursing Certification Board4700 W. Lake AvenueGlenview, IL 60025-1485800/229-7530 or 847/375-4710Fax 847/375-4777E-mail info@rehabnurse.orgWeb site http://www.rehabnurse.org

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Make aStrategic MoveEarn Certification inRehabilitation Nursing

ReferencesBeauchamp, T.L., & Childress, l.F. (1994). Principles ofbiomedical ethics

(4th ed.). New York: Oxford University Press.Butz, A.M., Redman, B.K., Fry, S.T., & Kolodner, K. (in press). Ethical

conflicts experienced by certified pediatric nurse practitioners in ambulatorysettings. Journal ofPediatric Health Care.

Caplan, A.L., Callahan, D., & Haas, J. (1987). Ethical and policy issues inrehabilitation medicine. Hastings Center Report, 17(Suppl. 4),1-19.

Fry, S.T. (1987). Demographic Data Form; Moral Conflict Questionnaire.Baltimore: University of Maryland.

Gray, B.H. (1997). Trust and trustworthy care in the managed care era.Health Affairs, 16(1),34-49.

1ameton, A. (1984). Nursing practice: The ethical issues. Englewood Cliffs,Nl: Prentice-Hall.

Mitchell, C. (1990). Ethical dilemmas. Critical Care Nursing Clinics ofNorth America, 2,427-430.

Redman, B.K., & Fry, S.T. (1996). Ethical conflicts faced by RN/certifieddiabetes educators: Report of a pilot study. The Diabetes Educator, 22,219­224.

Redman, B.K., Hill, M.N., & Fry, S.T. (1997). Study of ethical conflictsreported by certified nephrology nurses (CNNs) practicing.in dialysis settings.American Nephrology Nurses Association Journal, 24( 1),23-31.

Rest, l.R. (1986). Moral development: Advances in research and theory.New York: Praeger.

Rodney, P., & Starzomski, R. (1993). Constraints on the moral agency ofnurses. Canadian Nurse, 89(9),23-26.

Barbara Redman is a dean andprofessorat the University ofCon­necticut School ofNursing in Storrs, CT. Sara T. Fry is the HenryR. Luce professor ofnursing ethics at Boston College School ofNursing in Chestnut Hill, MA.

184 Rehabilitation Nursing > Volume 23, Number 4' Jul/Aug 1998