Ethical con¯icts reported by registered nurse/certi®ed diabetes educators: a replication

Barbara K. Redman PhD RN FAAN

Dean and Professor, Wayne State University College of Nursing,

Detroit, Michigan

and Sara T. Fry PhD RN FAAN

Henry R. Luce Professor Of Nursing Ethics, Boston College School of Nursing,

Chestnut Hill, Massachusetts, USA

Accepted for publication 6 November 1997

REDMAN B.K. & FRY S.T. (1998) Journal of Advanced Nursing 28(6), 1320±1325

Ethical con¯icts reported by registered nurse/certi®ed diabetes educators:

a replication

The purpose of this study was to identify types of ethical con¯icts reported by

certi®ed diabetes educators who are also registered nurses (RN/CDEs) and to

examine their relationship with demographic, educational and practice setting

variables. This study is a replication of an earlier pilot study. Ethical con¯icts

expressed by RN/CDEs in active practice in New York and Pennsylvania were

analysed according to four themes. Disagreement with medical practice was by

far the most dominant clinical context for the con¯icts (61%), as it had been in

the pilot study (75%). Participants believed that 32% of the ethical con¯icts

were resolved. Ethics committees and consultants were very rarely used. Of the

relationships between the kinds of con¯icts and their resolution, and demo-

graphic, educational and practice setting variables of the participants, only kind

of position was signi®cantly (P < 0á005) related to practice context of the ethical

con¯ict.

Keywords: ethics, ethical con¯ict, diabetes educator, nursing ethics,

moral distress, moral dilemma, patient protection

INTRODUCTION

Ethical con¯icts are an inevitable part of clinical practice.

These con¯icts emerge between ethical beliefs, duties and

principles and theories, in which each side of the con¯ict

is a morally defendable position (Mitchell 1990). Because

nurses are responsible for direct care and advocacy for

patients but often lack personal authority or access to

decision making channels, they are especially vulnerable

to experiencing ethical con¯icts. If unrecognized and

unresolved, ethical con¯icts can have a serious impact on

the ability of health professionals to deliver adequate care.

Con¯icts may also have a negative impact on nurses'

morale, sometimes being a causative factor in burnout and

exit from the ®eld (Rodney & Starzomski 1993). It there-

fore behoves each ®eld of practice to identify and develop

constructive ways to deal with commonly experienced

ethical con¯icts before their negative consequences

become serious.

Because what is perceived as an ethical con¯ict fre-

quently differs by ®eld of practice (Redman & Hill 1997) as

well as by discipline, it is useful to identify con¯icts and

examine their potential resolution by specialty andCorrespondence: Barbara K. Redman, Wayne State University College

of Nursing, 5557 Cass Avenue, Detroit, MI 48202, USA.

Journal of Advanced Nursing, 1998, 28(6), 1320±1325 Philosophical and ethical issues

1320 Ó 1998 Blackwell Science Ltd

discipline. This understanding forms the basis for cross-

discipline and cross-specialty discussions about ethics.

LITERATURE REVIEW

A review of 23 studies of ethical con¯icts described by

nurses, showed common areas of con¯ict by specialty.

Those practising in community home settings and in

administrative roles in general reported ethical con¯icts

around availability of resources for those in need. Studies

in intensive care units found con¯icts related to patient

and family suffering pain and the net good or harm of life-

prolonging aggressive theories (Redman & Hill 1997).

A search of the literature revealed very little attention to

ethical issues in the care of persons with diabetes, and

only one study of ethical con¯icts, how they are experi-

enced and resolved in this ®eld, could be identi®ed

(Redman & Fry 1996). This study of 43 RN/CDEs practis-

ing in Maryland, Virginia, or the District of Columbia

found that the majority of ethical con¯icts (75%) con-

cerned disagreement with the quality of medical care the

patient was receiving. The ethical principles most often in

con¯ict were bene®cence (moral obligation to do good for

others) and non-male®cence (moral obligation to not

in¯ict evil or harm). Most con¯icts were experienced as

dilemmas (two or more principles that seem to apply but

support mutually inconsistent courses of action). The

present study is a replication of the earlier Redman & Fry

(1996) study. The purpose was to extend and verify types

of ethical con¯icts reported by RN/CDEs and examine

their relationship with demographic, educational and

practice setting variables. The conceptual framework for

examining ethical con¯icts was: the practice context in

which ethical con¯ict occurred, ethical principles and

values in con¯ict, how the nurse experienced the con¯ict,

and the con¯ict's reported resolution.

THE STUDY

A descriptive survey design was used to obtain demo-

graphic data and descriptions of ethical con¯icts experi-

enced by RN/CDEs. The research protocol was approved

by the University of Connecticut Institutional Review

Board.

Sample

The sample was accrued in two phases. First, all Amer-

ican Association of Diabetes Educators (AADE) who were

identi®ed as RN/CDEs in the Association's 1996 Member-

ship Directory (n � 396), in New York (n � 221) and

Pennsylvania (n � 175) received survey instruments by

mail and were asked to participate. Eight surveys were

undelivered due to lack of current address. Two hundred

and ninety surveys (73%) were returned. Subject eligibil-

ity criteria for phase 2 included current practice as an RN/

CDE and indication of willingness to participate by

completion of the instruments. Of the 290 surveys re-

turned, 53 nurses indicated they were not working in

diabetes education while 108 indicated they did not wish

to participate and 26 questionnaires were incomplete.

Data analysis was done on the 103 returned and complet-

ed instruments. Of this number, 44 participants described

two con¯icts; these were included in the description of

con¯icts but not in analysis of relationships with demo-

graphic, educational and practice setting variables.

Instruments

The Demographic Data Form (DDF) is a questionnaire

designed to collect vital statistics and information about

educational background and clinical practice. The Moral

Con¯ict Questionnaire (MCQ), an open-ended question-

naire, was designed to elicit descriptions of ethical con-

¯icts in practice. The DDF and the MCQ were the survey

instruments. Participants were asked to describe a moral

(ethical) con¯ict they had experienced in their area of

nursing practice, why they perceived the situation as a

con¯ict, and how it was resolved. These tools originally

were developed and tested for content validity by Fry

(1987) and have been used in several other studies (Miya

et al. 1991, Redman & Fry 1996, Redman et al. 1997).

Analysis

Data from the DDF were analysed using descriptive

statistics. Each ethical con¯ict described on the MCQ

was analysed according to four content analysis schemes

in order to capture multiple meanings. The entire con¯ict

served as the unit of analysis. Categories for ethical

con¯icts within each classi®cation system are mutually

exclusive and exhaustive. The authors, each with formal

preparation in ethics, independently coded the ethical

con¯icts within each system, revising the codings and

their de®nitions until an inter-rater agreement of 100%

was obtained. Therefore, chance-adjusted agreement rates

(i.e. Kappa statistic) were not computed.

The ®rst content analysis scheme (Classi®cation System

I) describes the practice context of the con¯ict. The system

developed in the pilot study (Redman & Fry 1996), was

adapted to re¯ect expanded content categories from the

ethical con¯icts described in the present study. The

second content classi®cation scheme (Classi®cation Sys-

tem II) describes the ethical principles and values used by

subjects in describing the con¯ict. These concepts have

commonly understood meanings (Beauchamp & Childress

1994). The full classi®cation systems and de®nitions may

be found in Tables 3, 4, 5 and 6.

Classi®cation System III, the third content analysis

scheme, characterizes how the con¯ict was experienced

Philosophical and ethical issues Ethical con¯icts

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(6), 1320±1325 1321

using Jameton's (1984) de®nitions of moral con¯icts in

nursing practice. Jameton (1984) de®nes three major ways

an ethical con¯ict is experienced: (1) moral dilemma is

experienced when two or more clear moral principles

apply to the con¯ict situation, but they support mutually

inconsistent courses of action; (2) moral distress is expe-

rienced when one knows the right thing to do, but

institutional constraints make it nearly impossible to

pursue the right course of action; and (3) moral uncer-

tainty is experienced when one is unsure which ethical

principles or values apply or uncertain about the nature of

the moral problem. The fourth classi®cation system (Clas-

si®cation System IV) was guided by the categories from

prior studies (Redman et al. 1997, Butz et al. 1998) but

were mainly constructed from the present data. This

analysis scheme provides for a description of the con¯ict's

resolution or its non-resolution.

The relationship between kinds of ethical con¯icts and

demographic, educational and practice setting variables

were examined using chi-square tests and analysis of

variance. Participants who described con¯icts not judged

to be ethical in nature were of course excluded from the

analyses. When participants provided more than one

ethical con¯ict, the ®rst one was used for this analysis

(n � 103).

RESULTS

Description of participants

A description of the demographic characteristics of par-

ticipants appears in Table 1. The mean age of participants

was 47 years, and all were female. They were a highly

educated group, functioning in clinician/practitioner or

diabetes educator roles, with nearly 60% having been in

their present positions for 6 or more years. The majority

practised in hospital and community settings, with 19%

practising in diabetes education centres.

Exposure to ethics instruction was assessed by asking

participants to indicate the teaching of ethics by nursing

and non-nursing faculty and whether ethics content was

integrated into their programmes of study or provided by

speci®c ethics courses. Those participants who reported

multiple educational experiences were considered to have

had higher exposure to ethics instruction. The results,

presented in Table 2, show that integration throughout

their programmes of study was most common, with more

than a ®fth of participants reporting no ethics content or

course work in their basic nursing programme and 35% no

ethics content since their basic programme.

Description of ethical con¯icts

ContextThe clinical context for the ethical con¯icts described by

participants may be found in Table 3. By far the most

dominant context was disagreement with medical prac-

tice, especially situations where the diabetes educator

thought that patients were losing out because of inade-

quate or mismanaged treatment by the physician. This

®nding is consistent with that of the pilot study (Redman

& Fry 1996). Examples included acceptance by physicians

of poor control, insuf®cient monitoring, lack of screening

for early evidence of complications, inappropriate use of

insulin or other medications and generally not meeting

nationally de®ned standards.

A signi®cant number of the RN/CDEs reported that

disagreement with medical practice provided the context

for their ethical con¯icts. They clearly described how the

patient was `losing out' by following the treatment plan

recommended by their physician. Their knowledge about

diabetes care, on most cases, seemed to exceed that of the

physicians caring for diabetic patients, especially in

general practice settings. This is a consistent ®nding

Table 1 Demographic characteristics of participants (n = 103)

Age: range 29±72 yr; mean 46.7 yr

Sex: female (100%); male (0%)

Initial nursing

preparation: ADN (15%); diploma (46%); BSN (40%)

Highest academic

preparation (a): AD or diploma (11%);

doctorate (1%);

Bachelors (37%);

other (4%)

MSN or MS (47%);

Length in

present position: <5 yr (37%); 6±10 yr (28%) >10 yr (34%)

Primary area

of responsibility: staff nurse (10%); clinician/practitioner (43%); other (48%)

Practice setting (a): diabetes education centre (17%); hospital inpatient education (21%);

hospital outpatient education (35%); hospital both inpatient & outpatient

(50%); community diabetes education (46%)

a = Percentages do not add up to 100 because of multiple choices.

B.K. Redman and S.T. Fry

1322 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(6), 1320±1325

among nurses with advanced specialty education (Red-

man & Fry 1996, Redman et al. 1997). When RN/CDEs

tried to recommend changes in a patient's treatment plan,

congruent with practice standards, their efforts often

resulted in physician resistance to change and even

outrage that the nurse should presume to make recom-

mendations to the physician about patient care. In order to

avoid an acrimonious relationship with a physician, some

RN/CDEs would send the physician a copy of the most

recent standards of care and tactfully suggest changes for a

speci®c patient in writing. Other nurses would instruct

patients in standards of care for diabetes, then encourage

the patient to ask the physician speci®c questions or to

request a different treatment plan so that they might

receive more appropriate care. A few nurses feared con-

fronting a physician about a patient's treatment plan

because their action might result in losing future patient

referrals from the physician.

Principles/values in con¯ictThe most commonly perceived con¯icts were between the

duties to do good and avoid harm (the principles of

bene®cence and non-male®cence) and between doing

good and the duties to maintain patient trust in the

physician (see Table 4). RN/CDEs were caught between

wanting to protect patients from poor standards of practice

and knowing that patients needed to believe in the skills

of their physicians.

How con¯ict was experiencedParticipants were almost never uncertain about what the

moral problem was or what moral principles or values

were in con¯ict; rather, they experienced the con¯icts as

moral distress and feeling powerless to do the right thing,

or as moral dilemmas (see Table 5).

Con¯ict resolutionAbout one-third of the reported con¯icts were resolved

(see Table 6), most frequently by taking action to protect

patients or educating them to take action, such as to

question their physicians or seek other advice. An addi-

tional 29% of the participants took steps to empower

patients to change a problematic situation, although they

did not indicate whether this action resolved the con¯ict.

Another one-third of the con¯icts were described as

unresolved, with the RN/CDE simply coping as best she

could with the situation, often after an unsuccessful

discussion with physicians and administrators. Coping

involved continuing to educate staff and physicians about

national standards of care and being tactful with physi-

cians, and educating patients suf®ciently so that they

could make their own decisions about the medical advice

they were receiving. Ethics committees/consultants were

almost never used by participants to resolve ethical

con¯icts.

Relationship of ethical con¯icts with demographic,educational and practice setting variables

Only one statistically signi®cant relationship was found

between Classi®cation Systems I-IV and participants'

Table 2 Reported instruction in ethics (n = 103)

Basic

nursing

ed.

(%)

Since

basic

nursing

ed.

(%)

Integrated throughout programme of study 55 32

Ethics content in speci®c course 14 18

Ethics course taught by nursing faculty 23 15

Ethics course taught by non-nursing faculty 21 22

No ethics content & coursework 23 32

Percentages do not add up to 100 because of multiple choices.

Table 3 Classi®cation System I. Context for ethical con¯ict (n = 147 con¯icts)

Total (%)

Disagreement with medical practice

Patient losing out (inadequate/mismanaged treatment by physician) 57

Professional ethic (relationship with physician/how should cooperate/legal issue) 4

Professional duties/responsibilities (protection of patient rights, avoiding con¯ict of interest, other) 9

Patient non-adherence Ð patient refuses to follow prescribed regimen 6

Health policy Ð health policy under which RN/CDE is operating is perceived as unfair; usually involves

reimbursement and insurance issues.

6

Institutional constraints/roles. Lack of institutional resources of role support, or existing institutional policies

con¯ict with responsibility felt by RN/CDE to patients.

3

Research ethics Ð demands of research interfere with patient welfare 1

Not an ethical dilemma Ð con¯ict exists but is not moral in nature 14

Philosophical and ethical issues Ethical con¯icts

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(6), 1320±1325 1323

characteristics (initial nursing preparation, highest aca-

demic preparation; length of time in position; primary area

of responsibility; amount of exposure to ethics education;

and practice setting). Although all participants were RN/

CDEs, they functioned in various job roles and titles. Those

in staff nurse or clinician/practitioner roles were signi®-

cantly (P < 0á005) less likely to describe a con¯ict con-

cerning disagreement with medical practice than were

those in `other' roles including that of diabetes educator.

DISCUSSION AND IMPLICATIONS

Participants in this study may not be representative of the

larger population of RN/CDEs in New York and Pennsyl-

vania. Similarly, Classi®cation Systems I and IV, con-

structed from the data in this and the pilot study, may not

be representative of the practice context or the types of

con¯icts experienced by all RN/CDEs in these states. It

should also be noted that the study ®ndings do not

indicate how frequently the RN/CDEs experienced ethical

con¯icts in their practice. Despite these limitations, ®nd-

ings from the study are consistent with the previous study

and are compelling.

Findings from other studies related to diabetic care

tend to support the RN/CDEs' perceptions that patients'

diabetic conditions are often mismanaged by physicians.

Weiner et al. (1995) found that 84% of diabetics

participating in Medicare in three states, did not appear

to be receiving recommended tests and screening. Mar-

shall et al. (1996) obtained similar ®ndings in yet

another state. A forum examining treatment of type II

diabetes in Texas found inadequate education for both

patients and health care providers (Davidson 1997).

Marrero (1994) summarized multiple studies involving

primary care physicians and found considerable gaps

between current recommendations for diabetes care and

the physician's actual practice. Dunn & Bough (1996)

reported similar ®ndings in their study of 3974 patients

in 37 practices in Great Britain, as did Worrall et al.

(1997) in Canada, and Lipton and others (1996) with

Latino Adults in Chicago.

The reasons why nurses continue to cope with ethical

con¯icts in patient care have not been adequately studied.

Some nurses may cope with ethical con¯ict because they do

not know how to resolve the situation Ð in other words,

they do not have the skill to resolve the con¯ict. Other

nurses may fear that calling attention to an ethical con¯ict

or open disagreement with physicians or administration

will endanger their position or employment. For some

nurses, unresolved con¯ict indicates that the nurse does not

have the decision-making authority to resolve the con¯ict.

It is unclear what types of con¯icts are more resolvable

than others and under what conditions. It would also be

useful to know more about the characteristics of nurses

who do resolve ethical con¯icts by taking speci®c actions.

Why are some con¯icts perceived by nurses as more

morally distressing than others. Does the nature of the

con¯ict or the context under which it occurs have an effect

on whether the con¯ict is experienced by the nurse as a

dilemma or moral distress?

Table 4 Classi®cation System II. Principles/values in con¯ict

with other ethical principles or norms (n = 147)

Total (%)

Bene®cence1/non-male®cence2 38

Bene®cence/maintenance of patient trust in

physician

16

Bene®cence/autonomy3 12

Bene®cence/justice4 11

Bene®cence/nurse's self-interests 9

Bene®cence/maintenance of nurse/physician

relationship

7

Veracity5 6

Con®dentiality6 2

Not enough data 1

1 Bene®cence: moral obligation to do good for others.2 Non-male®cence: moral obligation not to in¯ict evil or harm.3 Autonomy: moral obligation to respect self-determination.4 Justice: moral obligation to treat others fairly or to treat those

with the greatest need ®rst.5 Veracity: moral obligation to tell the truth and not lie.6 Con®dentiality: moral obligation to refrain from disclosing

information.

Table 5 Classi®cation System III. How the con¯ict is experienced

(n = 147 con¯icts)

Total (%)

Moral distressÐarises when one knows

the right thing to do,

but institutional or other constraints

make it nearly impossible

to pursue the right course of action;

nurses may have neither the

personal authority nor access to

decision-making channels needed

to resolve the issue.

52

Moral dilemmaÐarises when two (or more)

clear moral principles

apply but they support mutually

inconsistent courses of action.

46

Moral uncertaintyÐarises when one is

unsure what moral principles

or values apply, or even what the

moral problem is.

1

Not enough data. 2

B.K. Redman and S.T. Fry

1324 Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(6), 1320±1325

Last, the limited literature on ethics related to diabetes

has focused predominantly on biomedical issues such as

fetal tissue transplants, gene therapy and genetic predic-

tion, treatment refusal in terminally ill persons with

diabetes and the rights and responsibilities of women to

control their diabetes during pregnancy. Ethical con¯icts

experienced by nurses have not been addressed, and

neither have ethical issues related to team care for persons

with diabetes. Clearly, there is a need to do so.

Acknowledgements

This research was supported by a grant from the Univer-

sity of Connecticut Research Foundation.

References

Beauchamp T.L. & Childress J.F. (1994) Principles of Biomedical

Ethics 4th edn. Oxford University Press, New York.

Butz A.M., Redman B.K., Fry S.T. & Kolodner K. (1998) Ethical

con¯icts experienced by certi®ed pediatric nurse practitioners

in ambulatory settings. Journal of Pediatric Health Care 12, 1±9.

Davidson J.A. (1997) The treatment of type II diabetes in Texas.

Diabetes Care 20, 446±451.

Dunn N.R. & Bough P. (1996) Standards of care of diabetic

patients in a typical English community. British Journal of

General Practice 46, 401±405.

Forchuk C. (1991) Ethical problems encountered by mental health

nurses. Issues in Mental Health Nursing 12, 375±383.

Fry S.T. (1987) Demographic data form; moral con¯ict question-

naire. Unpublished manuscripts, University of Baltimore,

Maryland.

Jameton A. (1984) Nursing Practice: The Ethical Issues. Prentice-

Hall, Englewood Cliffs, New Jersey.

Lipton R., Losey L., Giachello A.L. et al. (1996) Factors affecting

diabetes treatment & patient education among Latinos: results

of a preliminary study in Chicago. Journal of Medical Systems

20(5), 267±276.

Marrero D.G. (1994) Current effectiveness of diabetes health care

in the U.S. Diabetes Reviews 2, 292±309.

Marshall C.L., Bluestein M., Chapin C. et al. (1996) Outpatient

management of diabetes mellitus in ®ve Arizona Medicare

managed care plans. American Journal of Medical Quality

11(2), 87±93.

Mitchell C. (1990) Ethical dilemmas. Critical Care Nursing Clinics

of North America 2, 427±430.

Miya P.A., Boardman K.K., Harr K.L. & Keene A. (1991) Ethical

issues described by NICU nurses. Journal of Clinical Ethics

2, 253±257.

Redman B.K. & Fry S.T. (1996) Ethical con¯icts reported by

registered nurse/certi®ed diabetes educators. The Diabetes

Educator 22(3), 219±224.

Redman B.K. & Hill M.N. (1997) Studies of ethical con¯icts by

nursing practice settings or roles. Western Journal of Nursing

Research 19(2), 243±260.

Redman B.K., Hill M. & Fry S.T. (1997) Study of ethical con¯icts

reported by certi®ed nephrology nurses (CNNs) practicing in

dialysis settings. American Nephrology Nurses Association

Journal 24(1), 23±31.

Rodney R. & Starzomski R. (1993) Constraints on the moral agency

of nurses. Canadian Nurse 89(9), 23±26.

Viens D.C. (1994) Moral dilemmas experienced by nurse practi-

tioners. Nurse Practitioner Forum 5, 209±214.

Weiner J.P., Parente S.T., Garnick D.W. et al. (1995) Variation in

of®ce-based quality; a claims-based pro®le of care provided to

Medicare patients with diabetes. Journal of the American

Medical Association 273, 1503±1508.

Worrall G., Freake D., Kelland J., Pickle A. & Keenan T. (1997)

Care of patients with type II diabetes: a study of family

physicians' compliance with clinical practice guidelines. Jour-

nal of Family Practice 44, 374±381.

Table 6 Classi®cation System IV. Resolution of ethical con¯ict

(n = 147 con¯icts)

Total (%)

A Resolved

Took action to protect patient 12

Educated patient/family to take action 11

Decision made through team/family discussion 3

By ethics committee 2

Go along with other's decision 1

Other 3

B Not resolved

Nurse copes 20

Confront/discuss with physician/administration 13

Report to supervisor 2

Refer to ethics committee/consultant 1

C Empower patient to change the practice 29

D Nurse removed self from situation 1

E Not enough data 2

Philosophical and ethical issues Ethical con¯icts

Ó 1998 Blackwell Science Ltd, Journal of Advanced Nursing, 28(6), 1320±1325 1325