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The effect of ethical ideology and professional values on registered nurses' intentions to act accountably

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Title:
The effect of ethical ideology and professional values on registered nurses' intentions to act accountably
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Book
Language:
English
Creator:
Hartranft, Susan R
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University of South Florida
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Subjects / Keywords:
Nursing Staff -- ethics   ( mesh )
Ethics, Nursing   ( mesh )
Attitude of Health Personnel   ( mesh )
Ethical Relativism   ( mesh )
Retrospective Moral Judgment   ( mesh )
Moral development
Moral judgment
Patient safety
Responsibility
Moral distress
Dissertations, Academic -- Nursing -- Doctoral -- USF   ( lcsh )
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bibliography   ( marcgt )
non-fiction   ( marcgt )

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Summary:
ABSTRACT: Hospitals today focus on creating a culture of patient safety and reducing error. Registered nurses are mandated by the American Nurses Association's Code of Ethics to advocate for the patient at all times and to act accountably to ensure patient safety. There is a paucity of literature relating to how nurses' values and ethical ideology may affect their decision to act accountably. This study tested two hypotheses. Hypothesis 1 predicted that registered nurses who demonstrated a low relativistic ethical ideology would score higher on a measure of professional values than would registered nurses who demonstrate a high relativistic ethical ideology. Hypothesis 2 predicted an order of ethical ideology (absolutists then exceptionists, subjectivists and situationists) in scores on a measure of accountability. A descriptive non experimental design was used.Registered nurses (n=215) employed on the west coast of Florida completed a demographic form, Ethical Position Questionnaire (EPQ), Nurses Professional Values Scale Revised (NPVSR) and an investigator developed accountability instrument. A median split on the scores of the relativism and idealism scales on the EPQ formed the four groups of ethical ideology; absolutists, exceptionists, subjectivists and situationists. The accountability instrument consisted of 2 hypothetical clinical vignettes involving a late antibiotic administration. Using a Likert type scale, the participants answered three questions regarding how likely they would be to record the actual time of medication administration, call the physician and complete an incident report. Hypothesis I was not supported. Idealism (p=.001) not relativism had a significant effect on professional values. Hypothesis II was not supported.Absolutists scored highest on measures of accountability followed by exceptionists, situationists and subjectivists. When controlling for age, idealism not relativism had a significant effect on completing an incident report (p = .03). This is the first study to examine the effect of ethical ideology on professional values and a registered nurse's intention to act accountably. Previous studies described values held but did not link the descriptions to intentions to act. The information may be useful to hospitals as they build a culture of patient safety and develop a workforce that is accountable for its actions and decisions.
Thesis:
Dissertation (Ph.D.)--University of South Florida, 2009.
Bibliography:
Includes bibliographical references.
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by Susan R. Hartranft.
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Title from PDF of title page.
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Document formatted into pages; contains 115 pages.
General Note:
Includes vita.

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aleph - 002211018
oclc - 643078426
usfldc doi - E14-SFE0002844
usfldc handle - e14.2844
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The Effect of Ethical Ideolog y and Professional Values on Registered Nurses Intenti ons to Act Accountably by Susan R. Hartranft A dissertation submitted in partial fulfillment of the requirement s for the degree of Doctor of Philosophy College of Nursing University of South Florida Major Professor: Mary S. Webb, Ph.D. Jason W. Beckstead, Ph.D. Lois O. Gonzalez, Ph.D. Hana Osman, Ph.D. April 7, 2009 Key Words: moral development, moral judgm ent, patient safety, responsibility, moral distress Copyright: 2009 Susan R Hartranft

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Dedication To my husband, Tom, who has supported me throughout my pursuit of this degree. This support came in severa l forms and never faltered. He took over parenting duties, transporting our children to and from school, practices and games. He made lunches and picked up dinners. He encouraged me when I was discouraged. He was a source for statistics help and when stats progressed beyond what he knew, he read the book and completed the homework so he could look at my work and say its not what I got forcing me to review my work and find my mistakes. The simple phrase of thank you seem s woefully inadequate to express my gratitude for all you have done as I pursued this dream. Tom, this would have not been possible without you by my side, thank you.

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Acknowledgements I would like to extend my appreciation to my dissertation committee, Dr. Mary Webb (chair), Dr. Jason Beckstead, Dr. Lois Gonzalez, and Dr. Hana Osman for their guidance dur ing this long process. To Dr. Mary Evans, I am extremely grat eful for your guidance, support and wise counsel. In memoriam, Dr. Margre tta M. Styles (Grett a) and Dr. Imogene M. King (Imogene), your belief in my ability to comp lete this degree sustained me in times of doubt. A sincere thank you to Lisa Johnson, Darlene Ferenz, and Jackie Munro, who provided the freedom to flex my hours while pursuing this degree. Thank you to the Clinical Educ ation team who supported me over the years. To longtime friends Beth, Jean, Carol, Patti, Sandy, and to new friends Chris, Ron, Dan and Lee: thank you for your interest, concern and ability to pick me up. My family has served as a continuous source of support throughout this endeavor. To my parents, who came from PA to sustain hearth and home when I was busy and my husband was traveling. Thank you to my siblings, who offered words of encouragement. To my children, who have sacrificed time with their mother, thank you: Toby, whose dedicati on to academics has been a source of inspiration. To Emily, whose sunny smile is a source of joy.

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i Table of Contents List of Tables iv List of Figures vi Abstract vii Chapter One: Introduction 1 Introduction 1 Statement of t he Problem 3 Conceptual Model 6 Conceptual Definitions 7 Hypotheses 11 Purpose of the Study 12 Significance of Study 12 Summary 13 Chapter Two: Review of Literature 14 Introduction 14 Ethical Ideology 14 Values 19 Personal Values 20 Professional Values 25 Accountability 28 Summary 33 Chapter Three: Methods 37

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ii Research Design 37 Ethical Considerations 37 Sample and Sampling Procedure 38 Procedure 39 Operatioal Defiitions 40 Instruments 40 Information about Subjects 40 Ethical Position Questionnaire 41 Nurses Professional Values Scale Revised 41 Accountability Instrument 42 Data Analysis 44 Summary 45 Chapter Four: Results 45 Data Collection 45 Preliminary Statistics 45 Hypothesis 1 52 Hypothesis 2 55 Follow Up Significant Analyses 65 Hypothesis 1 65 Hypothesis 2 68 Summary 73 Chapter Five: Discussion 76 Discussion 76

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iii Significance of Findings 80 Implications 81 Recommendations for Future Research 82 Limitations 84 Conclusion 85 Summary 86 References 87 Appendix A Information About Subjects 105 Appendix B Ethical Posi tion Questionnaire 108 Appendix C Nurses Professional Values Scale Revised 110 Appendix D Accountabili ty Instrument 113 About the Author End Page

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iv List of Tables Table 1 Taxonomy of Ethical Ideology 8 Table 2 Taxonomy of Ethical Ideology/Ethical Philosophy 19 Table 3 Demographic Data 47 Table 4 Summary Descriptives of Continuous Variables 48 Table 5 Correlation Coefficients 49 Table 6 Bivariate Correlations for Accountability by Ethical Taxonomy 50 Table 7 Inter Item Reliability Coefficient 52 Table 8 Group and Marginal Means of Professional Values Scores By Ethical Taxonomy 54 Table 9 Analysis of Variance of Nurses Professional Values by Ethical Ideology 55 Table 10 Group and Marginal Means of Accountability Scores by Ethical Ideology 57 Table 11 Analysis of Covariance Accountability by Ethical Ideology With Professional Values as Covariate 58 Table 12 Adjusted Group and Margi nal Means of Accountability Scores by Ethical Ideology with Professional Values As Covariate 59 Table 13 Monotonic Trend Analysis 60

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v Table 14 Means of Individual Questi ons of Accountability Instrument By Taxonomy with Professiona l Values as a Covariate 63 Table 15 Analysis of Covariance of Individual Accountability Questions by Ethical Ideolog y with Professional Values as Covariate 65 Table 16 Group Means and Marginal Means with Professional Values By Ethical Ideology with Religiosity as Covariate 66 Table 17 Analysis of Covariance of Professional Values by Ethical Ideology with Religiosity as Covariate 68 Table 18 Means and Marginal M eans for Accountability Question 1 By Relativism and Idealism after Controlling for Age 69 Table 19 Means and Marginal Means for Accountability Question 2 By Relativism and Idealism after Controlling for Age 70 Table 20 Means and Marginal M eans for Accountability Question 3 By Relativism and Idealism after Controlling for Age 71 Table 21 Individual Accountabi lity Questions by Relativism and Idealism with Age as Covariate 72

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vi List of Figures Figure 1. Conceptual Model 7

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vii The Effect of Ethical I deology and Professional Values on Registered Nurses Intention to Act Accountably Susan R. Hartranft ABSTRACT Hospitals today focus on creating a cult ure of patient safety and reducing error. Registered nurses are mandated by the American Nurses Associations Code of Ethics to advocate for the patient at all times and to act accountably to ensure patient safety. Ther e is a paucity of literatur e relating to how nurses values and ethical ideology may affect their decision to act accountably. This study tested two hypotheses Hypothesis 1 predicted that registered nurses who demonstrated a low relativistic ethical ideology would score higher on a measure of professional values than would registered nurses who demonstrate a high relativistic ethical id eology. Hypothesis 2 predicted an order of ethical ideology (absolutists then except ionists, subjectivist s and situationists) in scores on a measure of accountability. A descriptive non experimental des ign was used. Registered nurses (n=215) employed on the west coast of Florida completed a demographic form, Ethical Position Questionnaire (EPQ), Nurs es Professional Values Scale Revised (NPVSR) and an investigator developed a ccountability instrum ent. A median split on the scores of the relativism and idealism scales on the EPQ formed the four groups of ethical ideology; absolutis ts, exceptionists, subjectivists and situationists.

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viii The accountability instrument consist ed of 2 hypothetical clinical vignettes involving a late antibiotic administrat ion. Using a Likert type scale, the participants answered three questions regarding how likely they would be to record the actual time of medicati on administration, call the physician and complete an incident report. Hypothesis I was not supported. I dealism (p=.001) not relativism had a significant effect on professional val ues. Hypothesis II was not supported. Absolutists scored highest on measur es of accountability followed by exceptionists, situationists and subjectivi sts. When controlling for age, idealism not relativism had a significant effect on completing an incident report ( p = .03). This is the first study to examine the effect of ethical ideology on professional values and a registered nurses intention to act accountably. Previous studies described values held but did not link the descriptions to intentions to act. The information may be useful to hospitals as they build a culture of patient safety and develop a workforce that is accountable for its actions and decisions.

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1 Chapter One Introduction Hospitals have focused on creating a cu lture of patient safety since the inception of the Institute for Healthcare Improvement in 1991 as well as the publication of To Err is Human (Kohen, 2000) and its com panion publication of Crossing the Quality Chasm (Institute of Medicine, 2001). Although specific federal legislation has not been enacted to address t he need for a culture of patient safety (Sharpe, 2004), 11 states to date have enacted some form of nurse staffing legislation (American Nurses Association, 2008). The Joint Commission in charge of the certification of hospitals has also adopted standards to establish a safe hospital environment. One reason hospitals seek Joint Commission certification is to be able to participate in federal Medicare and Medicaid reimbursement programs with deemed status (Joint Commission, 2008; Jost, 1994). This deemed status forces hospitals to create a safe patient environment. Creation of a safe environm ent for patients focuses on reducing error. Hospitals accomplish this through development of policie s and procedures based on standards of care, and by examining faulty processes that create error (Bayley, 2004; Morreim, 2004; Sharpe). This is in contrast to previous cultures in health care in which individuals were belie ved to be the cause of error (Sharpe). The policies and procedures develope d to create the safe patient environment include personnel policies and clinical procedures. These policies and procedures define the institutional expectations of the registered nurses

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2 conduct while at work. One such policy wo uld define the window of time available to the registered nurse to administer medications and have the medications considered by policy to be on time. T he policies that define on time medication administration are based on the physicians order for timing of administration (Allen & Barker, 1990). For ease of scheduling, hospitals adopted standard administration times (FitzHenry, Peterson, Arrieta, & Miller, 2005 ). The registered nurse records the actual ti me of medication administrat ion in the medical record. The hospitals expectation is that the medi cal record would show the medication administered within the accepted times, usually one hour before or after the ordered time. These instituti onal expectations may create a conflict of values for registered nurses if they are not able to provide medica tions to their assigned patients as they have been instructed and, at the same time, meet the institutional expectations. In addition to standards of care, ho spital policies and procedures, the registered nurse may be influenced by prof essional values. Professional values are those values held as important and integral to t he profession. These values may attract individuals into the profession, where they learn the values through the socialization process during prof essional education and upon entering the workforce (Jameton, 1984; Steele, 1983). For nursing, professional values are delineated in the Americ an Nurses Association Code of Ethics that first was developed in 1950 with the latest re vision occurring in 2001. The Code of Ethics defines relevant ethical obligations and duties nurses have not only to the public but to themselves (Fowler, 2008, p.43).

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3 When registered nurses perceive c onflict between their employers expectations and their own professiona l values, some have been shown to misrepresent their actions (Grover 1993a, 1993b) or to abandon their values (Ham, 2004). When the conflict becomes too complex to resolve, some nurses may leave their employment (Hart, 2005; Kupperschmidt, 1998; McNeese-Smith & Crook, 2003). Given the complexity of caring for crit ically ill hospitalized patients and the emphasis on cost effectiveness and pati ent safety, the potential for values conflict in the hospital setting is inevitabl e. Although the values conflict could be manifested in many ways such as calling in sick, extending breaks or leaving the organization, Grover (1993a, 1993b) found registered nurses who scored low on a measure of moral development misrepr esented their actions when faced with a conflict between their professional values and organizational expectations. If registered nurses choose to misrepresent their actions by recording in the medical record the expected and not the actual time of administration, the potential for patient harm may increase. Th is creates an unsafe environment in institutions whose mission is care, comfort and healing. Statement of the Problem The medical record is a document in which the potential conflict of professional values and organizational expectations may be demonstrated. From an ethical standpoint, when a registered nurse fails to meet organizational and professional expectations, it is consi dered a breach of duty. A medical record provides the factual documentation of a patients hospitalization and his or her

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4 care. Because decisions regarding medi cal care and treatm ent are made based on the information contained in the record, it is assumed by health care workers that all information entered in this document is accurate. For example, hospitals have standard policies for times that medi cations are to be administered. Such policies typically state that medications will be given within one hour on either side of the established time. A medica tion to be given at 10:00 could be administered within a time range of 09:00 to 11:00 and still be considered on time. With the number of medications received by patients and the number of patients for which the registered nurse may have responsibility, it is estimated a nurse could administer up to 50 different drugs in one shift (Rassin, 2007). It is challenging to deliver the volume of medications within the time frame that constitutes on time medication administration. When medications are administered outside the time frame dict ated by policy and procedure, it is considered a medication error committed by the nurse. Nursing errors are expressed as breaches of either nursing content or of nursing role authenticity (nursing identity) (Biordi, 1993, p. 39). Elfering (2006) found that medication errors are ranked second in safety-related stressful events for registered nurses. When faced with a medication error, it is often tempti ng for a registered nurse to record a time of administration that falls wi thin the expected parameters despite the fact that he or she actually administered the medication outside the expected parameters. Under such circumstances, the medical record would be a misrepresentation of the actual behavio r. For the registered nurse, this misrepresentation may create a value conflic t that is labeled in the literature as

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5 moral distress (Pendry, 2007) or ethical distress (West, 2007). Moreover, such value conflict may create an unsafe environment for the patient. The American Nurses Association (ANA) Code of Ethics (2001) provides a framework of ethical behavior for practi cing registered nurses. Additionally, it addresses the nurses duty to ensure patient safety and to follow institutional guidelines to report errors (ANA, 2001) Nurses, however, continue to be challenged to make ethical decisions in num erous clinical situations, leading to values conflict. Varcoe et al. (2004) identif ied this as working the in-betweens. Nurses described working between their ow n values and those of their employing institution. One way to understand these va lues conflicts would be to determine the state of a practicing r egistered nurses ethical ideo logy and the strength of his or her professional values. Once the registered nurses ethical i deology and strength of professional values are established, the extent to which the registered nurse demonstrates one particular value, such as accountabi lity, could be assessed by way of a hypothetical but realistic clinical scenario of a late medication administration. Accountability was chosen as the focus of this study because it is the value registered nurses must demonstrate in all facets of their work environment. A medication administration scenario was c hosen to assess accountability because it is a task a registered nur se performs many times during a shift. It is reasonable to expect that a registered nurse has fac ed situations in which a medication is late because he or she did not administer it within the establis hed time frame for an on time medication. In this situation, the registered nurse must decide what

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6 time to document in the medical record She or he could document either the actual time of administration or the ti me that the medication was scheduled for administration. If a registered nurse records the expect ed time of administration and not the actual time, it may have implic ations for patient safety and efficacy of treatment. The implications would be rela ted to the timing of the medication effect. For example an antib iotic is timed to maintain a steady blood level of medication. When an antibiotic is admin istered late but the medication is documented as being administered on time and the patient begins to demonstrate signs of worsening infection, the physician may assume the antibiotic is not effective and change it to another. Additionally because of the late medication and the re-emergence of symptoms, the patients hospital stay and recovery may be prolonged. With the knowledge regarding registered nurses documentation related to medication administration time, hospitals can develop policies and procedures and im prove staffing, which may assist registered nurses in their clinical prac tice and provide a sa fer environment for patients. Conceptual Model The conceptual model for this study, illustrated in Figure 1, consists of three concepts: (a) ethical ideology, (b) professional values, and (c) accountability. The model illustrates the effect of ethical ideology on accountability. Similarly, t he model illustrates the impa ct of ethical ideology on the development of the nurse s professional values. Ad ditionally, the influence of

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nurses professional values is illustrat ed in the model. The purpose of the study is embedded in this relationship. Nurses Professional Values Ethical Ideology Accountability Figure 1. Conceptual model Conceptual Definitions Ethical ideology consists of the degr ee of relativism (use of universal moral rules) and idealism (belief that good can come of all situations) exhibited by individuals when they make an et hical decision (Forsyth, 1981). A highly relativistic individual would reject moral principles to analyze situations individualistically. Someone who follows universal moral principles or rules would be an individual low in relativism. The Ethical Position Questionnaire (Forsyth, 1981) measures ethical ideology by cat egorizing the respondents as high or low in the ethical terms of relativism and i dealism, thus allowing them to be further 7

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8 categorized into one of four ethical ta xonomies: Situationist, subjectivist, absolutist, and exceptionist (see Table 1). Table 1 Taxonomy of Ethical Ideology High Relativism Low Relativism High Idealism Situationist Rejects moral rules; advocates individualistic analysis of each act in each situation; relativistic Absolutist Assumes that the best possible outcome can always be achieved by following universal moral rules Low Idealism Subjectivist Appraisals based on personal values and perspective rather than universal moral principles; relativistic Exceptionist Moral absolutes guide judgment but pragmatically open to exceptions to these standards; utilitarian The process of moral judgment or ethica l decision making has its origin in an individuals ethical ideology. Ideology is composed of the ethical terms of relativism and idealism. Relativism is the extent to which an individual accepts or rejects universal moral rules. Idealism is the belief that decisions can be made that will please those affected by the decision (Forsyth 1980, 1981, 1985; Forsyth & Pope, 1984). The relativistic individua l does not rely on universal moralistic

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9 principles to make ethical decisions but rather on his or her own personal belief system that may shift based on the situat ion. Idealistic individuals believe desirable consequences can be achieved without violating ethical guidelines. These guidelines may be universally acc epted ethical principles or their own personally developed gui delines. Ethical ideology as defined by Forsyth develops when the ethical groups of relativism and idealism are divided into high and low, thus forming the four ethical taxonomic groups illustrated in Table 1. A situationist is highly idealistic and re lativistic. A situationist would reject universal moral rules and individually analyze each act in each situation making the decision that would maximize the good or minimize the bad. In contrast a subjectivist is highly relativistic and low in idealism. The subjectivist, like the situationist, will ex amine situations using his or her own moral principles and not universally accept ed principles. Unlike the situationist, subjectivists are not idealistic and do not believe that good will result from all decisions. Absolutists are low in relativism and high in idealism. Absolutists believe in using universal moral principles to gui de decisions. They believe good will always result when universal principles are used. The exceptionist is low in both relati vism and idealism. An exceptionist will use universal moral principles when making decisions but would be willing to consider exceptions to these universal pr inciples to lessen the negative effects of the decision.

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10 In a situation such as a late medi cation administration, where conflict between nursing role performance and hospi tal policy is involved, registered nurses identified as situationists, by usi ng their own moral principles as a guide, might choose to act in the way that will br ing the greatest good. If the patient was not suffering any ill effect from the late medication administration, the situationist would most likely document the actual time the medication was administered. By choosing this action the patient does not suffer and the situationist does not come under scrutiny from their employer. In contrast a registered nurse identifi ed as a subjectivist might consult his or her own personal belief system to re solve the conflict. Consideration of bringing about the greatest good would not enter the decision-making process for a subjectivist. The subjectivist would document the expected and not the actual time of medication administration. An absolutist might follow universal mora l principles or professional values such as the ANA Code of Ethics to resolve the conflict in the belief that this will serve the greater good. Therefore an absolutist would document the actual time of administration whether the patient was suffering any ill effects or not. While an exceptionist might consider the ANA Code of Ethics if another possible solution is available that make s the conflict resolution easier for all involved, the exceptionist will consider other principles and choose the more practical solution. So the exceptionist would probably document the actual time of administration if the patient was exper iencing adverse effects from the late

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11 medication administration. If the patient was not suffering adverse effects the exceptionist would document the expected time of administration. Professional values for nursing are the values identified by the ANA Code of Ethics with Interpretive Statements The Code of Ethics is a succinct statement of the ethi cal obligations and duties of ev ery individual who enters the nursing profession. It is the professi ons nonnegotiable ethi cal standard and it expresses nursings own understanding of its commitment to society (ANA, 2001, p 5). The Code of Ethics is composed of nine provisions with accountability defined in Provision 4. T he nurse is accountable for individual practice. The interpretive statement for Provision 4 further defines accountability as: to be answerable to oneself and others for ones own actions. In order to be accountable, nurses act under a c ode of ethical conduct that is grounded in moral principles of fidelity and respect for the dignity, worth, and self-determination of patients. Nurses are accountable for judgments made and action taken in the course of nursing practice, irrespective of health care organizations policies or providers directives (p. 16). Hypotheses The following hypotheses were tested in the study: 1. Registered nurses who demonstrate a low relativistic (absolutist or exceptionist) ethical ideology will score higher on a measure of professional values than will regi stered nurses who de monstrate a high relativistic (situationist or s ubjectivist) ethical ideology.

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12 2. Absolutists are more likely to ac t accountably in hypothetical clinical situations than exceptionists. Exc eptionists are more likely to act accountably than are subjec tivists and subjectivists are more likely to act accountably than are situationists. Purpose of the Study The first purpose of this study was to identify the influence of ethical ideology on the professi onal values held by regi stered nurses. The second purpose was to determine the extent to which registered nurses demonstrated the professional value of a ccountability when faced with hypothetical medication administration clinical sit uations. This study exami ned the relationship among ethical ideology, professional values, and accountability. Further, it represented the next step in descriptive research, which was to examine if professional values and ethical ideology are predi ctive of registered nurses behavioral intentions to act accountably in hypothetical clinical situations. Significance of Study Despite a more than a 100-year history of research on the values held by nurses and nursing students, there were no published generaliz able descriptive data that would create a pictur e of the values held by t he typical registered nurse. There were no published clinical data to support an assumption that registered nurses in clinical situations would dem onstrate values they claimed to hold. Development of professional values begi ns with the educational preparation for entering the profession, t hus the American Associati on of Colleges of Nurses (1998) has identified core knowledge of ethics, including accountability for own

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13 practice, as desirable for baccalaureat e nursing students to hold at graduation. The National League of Nursing Accr editing Commission (NLNAC), which accredits all levels of nursing educati on programs, expects nursing education programs to prepare practitioners to m eet professional standards (NLNAC, 2008). Among those professional standards is accountability as identified in the ANA Code of Ethics According to the code, the nurse is accountable for making appropriate decisions regarding practice even if the nurse perceives that his or her actions would be counter to instit utional policies and procedures. The code directs the nurse to comply with all laws regarding licensure and delegation. It would be useful for health care facilit ies, in the interest of patient safety, to determine if all registered nurses have internalized this value of accountability. If they have not, it will be necessary for employing organizations to have this information in order to facilitate the devel opment of processes that support the nurse, meet regulatory guidelines and assure patient safety. Summary This chapter presented the background, purpose, conceptual framework, conceptual definitions, and si gnificance of the study. Chapter Two presents the review of literature for t he concepts of ethical ideology, nurses professional values and accountability.

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14 Chapter Two Review of Literature: Introduction Registered nurses employed in hospi tal settings may find themselves struggling with the conflicting expectations of their employers and their individual professional values (Varcoe et al., 2004). When this occurs, some registered nurses may be inclined to misrepresent their actions (Grover, 1993a; 1993b). The medical record is a place where this conflict may be manifest. Decisions regarding treatment are bas ed on the information contained in the medical record. A falsified medical record does not present an accura te picture of the patients response to medical treatm ent. When decisions are made based on falsified information patient safety may be compromised. Currently the literature holds only descriptive data that would cr eate a picture of the values held by the typical registered nurse. There appears to be a lack of data to support the idea that registered nurses in clin ical situations actually dem onstrate the values that they claim to hold. Research is nece ssary to advance the current knowledge in this area. This chapter presents a review of the relevant literature pertinent to the three concepts of ethical ideology, professional values and accountability that form the basis for this study. Ethical Ideology The review of ethical ideology lit erature begins with a review of the process of moral development. Moral devel opment must occur before an ethical

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15 ideology is realized. Dewey (Archambaul t, 1964) was the first to suggest that moral development occurred in stages. He suggested that individuals take a rational approach to the personal decis ions required when faced with moral conflict, and that academic education is for the purpose of moral development and to provide the optimum environment for that learning. Piaget (Ketefian, 1981a) recognized moral development as occurring in three stages. For Piaget, intellectual dev elopment and moral development took place on a parallel course. When individuals reach Piagets highest level of moral development, the autonomous stage, they follow rules not because they have to but because of their free will to do so, bol stered by their use of principles and rules to guide behavior. Like the other pioneers in this area, Kohlberg (1981) defined three global stages of moral development: pre-c onventional, conventional, and post conventional. In the post conventiona l level of development, the individual autonomously examines and defines moral values and principles apart from group norms and culture. Cognitive growth is necessary along with moral growth to move to higher levels of moral development. Because of the cognitive factor necessary for moral development not all individuals will reach the post conventional stage. Gilligan (1977) proposed three global stages for moral development. Although she states her work is based on theme and not gender (p. 2) she writes her goal is to expand the under standing of human devel opment by using the group left out in the construction of theor y to call attention to what is missing

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16 in its account (p. 4). Gilli gans first stage is characterized by focus on self for individual survival. She then posits a transitional phase where the focus goes from selfishness (concentration on self ) to responsibility. Phase two is characterized by goodness (watching out for and caring about others; self sacrifice) being equated with se lf satisfaction. The transition to phase three is the movement from goodness to truth. In phase three, moral development is achieved through focus on deliberately unc overing self-needs and contemplating the effect of self-sacrifice on self and others (Gilligan, 1982; Belknap, 2000). Unlike Dewey, Piaget and Kohlberg, Gilligan did not assign chronologic age to her phases of development but instead focuses on changes in sense of self. Ketefian (1981a) studied nurses and nursing students and found a significant and positive correlation between cr itical thinking and moral reasoning (p. 171). Ketefian (1981b) also found a positive relationship between moral reasoning, knowledge and valuing mora l behavior in nursing dilemmas. In addition she found a relationship betw een moral reasoning and the nurses perception of realistic moral beha vior in nursing dilemmas. All four theories of moral development and decision contain three stages for moral development. Moreover, each c ontains a description of related cognitive maturation. The level of mora l development achieved will determine the individuals response to moral dilemmas. Although the theories of moral devel opment provide a process for ethical decision making, they do not elaborate on the decision-making process. Forsyth (1981) proposed a decision-making model ba sed on ones ethical ideology. This

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17 model has been used to evaluate ethical decisions in several areas, including business (Cui, 2005; Davis, 2001; Douglas, 2007; Ho, 1997; Sommer, 2000; Tansey, 1994), education (Deering, 1998), and religion (Watson, 1998). Studies using the Ethical Position Questionnaire (EPQ) were descriptive in nature comparing Russian and American busi nessmen (Sommer, 2000), Egyptian and American managers (Douglas, 2007), British and American undergraduate education students (Deering, 1998), consumer s in Austria, Britain, Bruni, Hong Kong and the United States of America (Cui, 2005). These authors found ethical ideology as measured by t he EPQ was not affected by na tionality. Tansey (1994) found that moral judgments of life insurance agents related to their personal moral philosophies. In a search of the available literature, none regarding nurses ethical decision making using the Et hical Position Questionnaire was found. The process of moral judgment or ethical decision making is based on an individuals ethical ideology. Ideology is composed of relativism and idealism. Relativism is the extent to which an i ndividual accepts or rejects universal moral rules. Idealism is the belief that decis ions can be made that will please those affected by the decision (Forsyth 1980, 1981, 1985; For syth & Pope, 1984). The relativistic individual does not rely on universal moralistic principles to make ethical decisions but rather on his or her own personal belief system that may shift based on the situation. Idealistic i ndividuals believe desirable consequences can be achieved without viol ating ethical guid elines. These guidelines may be universally accepted ethical principles or their own personally developed guidelines.

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18 Each of the ethical ideologies can be compared to a specific category of ethical philosophy and are illustrated in Tabl e 2. The highly relativistic individuals (situationists and subjectivist s) are characterized as ethical skeptics, meaning they do not attempt to endorse specific mo ral principles. The situationists would support Fletchers (1966) situation ethics, which is a contextual approach to action rather than good or bad. Subj ectivists would be categorized as ethical egoists because of their practical approach to evaluating their actions (Forsyth, 1980). In contrast, individuals with low rela tivism (absolutists and exceptionists) do use moral or ethical guiding principl es. Absolutists, because they reject consequences as a decision-making st rategy and believe that moralistic principles or rules are the foundation for all actions, are compared with the deontological approach to moral philosophy Exceptionists can be compared to Teleologist philosophy, which contends the morality of an action depends upon the consequences produced by the action (Forsyth, 1980). In a clinical situation such as the decision to remove a patient from life support, the individuals with low relativism (absolutists and exceptionists) will use the ethical principles of justice, nonmalefecence, autonomy and beneficence to make their decision. The absolutist becaus e of their idealistic beliefs would use beneficence as their primary principle. The highly relativistic individuals (situationists and subjectivists) would not consult ethical principles but would consider the situation, such as the patients age, family situati on or the conditions under which the patient was placed on life support. Furthermore, the situationist would consider how a good outcome can be achieved.

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19 Table 2 Taxonomy of Ethical Ideolog ies with Ethical Philosophy High Relativism Low Relativism High Idealism Situationist/Situation Ethics Rejects moral rules; advocates individualistic analysis of each act in each situation; relativistic Absolutist/Deontological Assumes that the best possible outcome can always be achieved by following universal moral rules Low Idealism Subjectivist/Ethical Egoist Appraisals based on personal values and perspective rather than universal moral principles; relativistic Exceptionist/Teleological Moral absolutes guide judgment but pragmatically open to exceptions to these standards; utilitarian. Values Values are beliefs that guide behavior to the end of an action that is deemed desirable. Values have a cogni tive, affective, motivational, and behavioral component. Values guide individual behavior (Rokeach, 1973). Once a value is internalized it becomes c onsciously or unconsciously a standard for guiding action, judging self and compari ng oneself to others (Steele, 1983). Personal values develop from life experie nces and usually remain consistent

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20 through life although they can be modi fied based on later life experience (Jameton, 1984; Rokeach, 1973; Steele, 1983). Professional values develop through the education process, which is designed to prepare individuals for entry into the profession (AACN, 2008; Alfred, 2005; Bjorkstrom, 2007; Martin, 2005). Professional values development is believed to continue past graduation and entry into the profession (ONeill, 1973; Thurston, 1989; Vincent, 1993). The individual will enter pr ofessional education with personal values developed from his or her life experiences (Bjorkstrom, 2007; Horton, 2007); therefore a review of the personal values literature will precede the review of the prof essional values literature. Personal values. Historically, the study of values held by nurses began with the study of nursing students to identify characteristics that would be desirable in a nurse. These identifi ed characteristics included physical and mental health, maturity, modesty, trus ting, loyalty, and comforting (Eads, 1936; Holliday, 1961; Ingmire, 1952; MacAndrew, 1959). Only one author in these early studies (Miles, 1933) identified intelli gence as a desirable characteristic. In the ensuing years, there was consi derable interest in describing the personality characteristics of nursing students, often in comparison to nonnursing students. The Edwards Personal Preference Schedule Inventory was used in nine studies to describe the pers onality of nursing students. In seven of the studies (Bailey & Claus, 1969; Gro ssack, 1957; Levitt, Lubin, & Zuckerman, 1962; Redden & Scales, 1961 Schulz, 1965; Smith, 1968; Stein, 1969), results were essentially the same. Nursing st udents in both baccalaureate and diploma

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21 programs scored higher than non-nursing college st udents on the concepts of deference, nurturance, intrac eption (to be interested in motives and feelings; to analyze the feelings of others) and endurance (Levitt, 1962) The nursing students scored lower than non-nursing coll ege students in the measures of autonomy, dominance, and exhi bition (to be the center of attention). Based on these findings, the ideal student nurse would be described as respectful, sympathetic to others, persi stent, introspective, convent ional, a follower and one who shuns attention. In 1970, Adam s and Klein administered the Edwards Personal Preference Schedule to bacca laureate nursing students and, for the first time, the nursing student s did not score significant ly differently than nonnursing college students on measures of endurance. The current nursing students scored essentially the same as previous nursing student groups on exhibition, dominance and change. Kahn (1980) found no significant difference between baccalaureate nursing students and non-nursing colle ge students on the autonomy and deference scale of the Edwards Pers onal Preference Schedule. Scores on autonomy increased and deference scores dec reased for baccalaureate nursing students when compared to previous st udies. Earlier studies (Burns, 1978; Sullivan, 1978; White, 1975) showed nurse practitioners scores on the Edwards Personal Preference Schedule were lowe r on deference and higher on autonomy than previous undergraduate students. Kahn suggested that this finding supported a change in the profile of nur sing students on the scales. However the

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22 small number of participants in Kahns st udy precludes generalization of a major change in personality characteristics in baccalaureate nursing students. In the 1960s and 1970s, researchers became interested in the personal values held by nursing st udents. There was interest in whether students chose the appropriate program for their val ues (Dustan, 1964), whether nursing students held different values than female college students in general (ONeill, 1973;Redman, 1966), whether values c hange during nursing education (May & Ilardi, 1970), and whether there had been a change in values over a decade (Garvin & Boyle, 1985). All of these researchers used the Allport-Vernon-Lindzey ( AVL ) scale to measure the values held by nursing students. The scales in the AVL measure the following six basic value types: theoretical, economic, aesthetic, social, political and religious (May & Ilardi, 1973). The scales are interdependent so an increase in the score on one scale will create a decrease in another. The social and religious values of t he Allport-Vernon-Lindzey Scale were considered to represent traditional nursi ng values. Nursing students consistently identified religious values as the most important value, while social values scored second. The one exception to this was t he associate degree nurses in Dustans (1964) study who indicated social values were more important, with religious values being second. Nursing students in all studies scored higher than the general female college population on the religious and social scales (Dustan; ONeill, 1973; Redman, 1966). In one longitudinal study, nursing students

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23 religious value score decreased during the education process; this was the case even though it was still the highest -ranking value (May & Ilardi, 1970). Two research studies (ONeill, 19 75; Redman, 1966) compared the scores of faculty and students on the Allport-Ve rnon-Lindzey Scale. In Redmans study the faculties scores indicated values different from the students scores. For faculty, the highest score was the aesthetic score (t he aesthetic person values beauty and harmony), followed by the theoretical score and the religious score, respectively. Redman hypothesized that either a decrease in the social score represented an absolute decrease in ot her values, or it represented a supplanting of values, such as by theoret ical values (discovery of truth), which are more important to the teaching role. ONeill found t he greatest agreement between values held by faculty and student s during the students junior year. ONeill expected greatest agreement would occur in the senior year after the students had maximum exposure to facult y. Academic achievement did not predict agreement between values held by the students and faculty. This might indicate that faculty interaction in the classroom may not influence value development. ONeill suggested the faculty provide opportunities to help students identify their values. Garvin and Boyle (1985) used the Allport-Vernon-Lindzey Scale to compare the values of nursing students entering the baccal aureate program in 1982 with the values of nursing students wh o entered the baccalaureate program in 1972. The only significant differenc e found was that the class of 1982 scored significantly higher on the economic scale (valuing what is useful and practical).

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24 The significant change in the economic scale was believed to be indicative of the current economic times. In keeping with what are considered to be typical nursing values, both groups ranked social values highest; religion ranked third in 1972 and second in 1982. The theoretical sca le (discovery of truth) was rated higher than the political scale in both groups. The Rokeach Value Scale (Rokeach, 1973) was used in three studies to measure the values held by nursing student s. This scale is used to assess the respondents ranking of 18 instrumental and 18 terminal values. Instrumental values measure prefe rred modes of conduct, for example, capable, broad-minded, logical and loving. Terminal values measure preferred end state of existence such as, an exci ting life, mature love, inner harmony and true friendship. Terminal and instrumental values are interdependent (Rokeach, p. 119). Blomquist, Cruise, and Cruise (1980) used the Rokeach Value Scale to measure the values of sophomore and s enior baccalaureate nursing students at four universities. The purpose of the study was to see if there was a difference in values between students in religious and se cular schools. There were significant differences in 15 of the 18 instrumental values and 10 of 18 terminal values. The authors found a significant difference betwe en freshman and senior students in 10 of the 18 instrumental values and se ven of the terminal values. All students valued honesty, with the score increasing between freshman and senior year. The instrumental values of helpful ness and cleanliness decreased through the educational process for all students. This was surprising because the basic

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25 tenets of helpfulness and asepsis are so important in nursing. This study demonstrated education did affect some values; however these were not necessarily values associated with traditional nursing, such as caring, honesty, and responsibility. Thurston, Flood, Shupe, and Gerald (1989) used the Rokeach Value Survey and a second survey based on the American Association of Colleges of Nursings seven essential values to identify the values held by faculty and new baccalaureate nursing student s. The faculty complet ed both instruments while the students completed only the Rokeach. T he faculty ranked integrity as the top American Association of Colleges of Nu rsings value followed by honesty and caring. This study showed faculty and student values are more in harmony than not. It validates the findings of ONeil (1973) and Williams ( 1978). A summary of these studies indicates that the typical nursing student enters professional education holding the values of re ligion, honesty and altruism. Most recently, Rassin (2008) surveyed Israeli nurses and found the instrumental values of honesty, responsibility and intelligence were rated as the most important personal values. Altruism and confidentiality did not rank highly. This does represent a change in pers onal values of nursing students when compared with ONeill (1973) and Williams (1978). Professional values. Professional values in nur sing were first reported in the nursing literature by Schank and Weis (1989). In this study, nursing students, registered nurses (one year after graduat ion) and experienced nurses (five years beyond graduation) provided demographic information, and identified their

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26 professional values. Nursing students and experienced nurses identified human dignity, responsibilit y, and accountability as the most important values. Nurses at one year after graduation identified the same values as nursing students and nurses with five years experience but in inverse order (accountability, responsibility ad human dignity). Neither nursing students nor experienced nurses consistently identified values related to economic welfare (conditions of employment) or to communi ty health. Because these values are generally associated with full professional socializat ion, the results from Schank and Weis (1989) suggested that work experienc e alone does not lead to complete professional socializ ation of nurses. Kellys studies of British and American nursing students (1991, 1992) found similar professional values betw een the groups. As examples of their values, British students ident ified respect for the pat ient and caring about the little things, defined as spending unrushed time on back rubs and other acts of caring (Kelly, 1991, p. 870). The Amer ican students identified respect for patients and caring as pr imary values. Like their Br itish counterparts American nursing students described caring as doing the little things (Kelly, 1992, p. 13). A descriptive study of pr ofessional values as measured by the Nurses Professional Values Scale (Martin Yarbrough, & Alfred, 2003) found no significant differences between values held by 1,450 associate degree nursing students and baccalaureate nursing students from all nursing programs in Texas. Ethnicity was an apparent factor, however, and was found to be related to significant differences on the three s ub-scales that measur ed dignity, client

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27 advocacy, and community/global health c oncerns. Asian/Pacific Islanders scored lower than the other student groups (Caucasians, African Americans, Hispanics, and Native Americans) on the human dignity subscale, and lower than all the other groups except Native Americans on safeguarding the patient and the public. Caucasian students scored lowe r than African-American and Hispanic students on collaboration to meet public health needs. As with personal values, other studies hi ghlighted interest in identifying the professional values held by nursing facu lty (Eddy, 1994; Elfrink, 1991). Initially researchers were interested in facu lty opinion on the importance of the American Association of Colleges of Nursings Essential Values for nursing student education. Although faculty deemed val ues training as important, most respondents did not include values training in their formal education plans (Elfrink & Lutz, 1991). Further, when surveyed, facu lty identified equalit y, human dignity and freedom as important essential values (E ddy, Elfrink, Weis & Schank, 1994). In a comparative study of British a nd American nursing faculty, Weis and Schank (2000) used the Nurses Professi onal Values Scale (based on the ANA Code of Ethics ) to identify comparable professi onal values. They found British nursing faculty were more likely to partici pate in research, as well as to use the results of research in their practice. They were also more likely to participate in promotion of British public health issues. This would suggest that British nurses had incorporated professional values more completely than did their American counter parts.

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28 Accountability Accountability is an integral characte ristic that all health professionals must demonstrate. Health care literature about accountability contains topics that include concern for the conf identiality of the electroni c medical record (Myers, 2008) and actualizing accountability through shared governance, which is decentralized decision making with shared ow nership and accountability (Moore, 2007). Outside healthcare, accountability is of interest to many disciplines; however, there have been few studies publi shed. Rather, the focus is on which individual or group is responsible for accomplishing a task or for overseeing a program. One example of current acc ountability literature can be found in the area of education. State governmental agencies in Colorado (2008) and Texas (2008) are concerned with educati onal accountability in the implementation of the No Child Left Behind legislation. Additional concerns regarding accountability in education include balanci ng public, academic, and market demand (Burke, 2005); mentoring new teachers (Stei ney, 2008); and fostering professional development (Moscinski, 2008) and account ability to students (Glicker, 2007; OSullivan, 2008; Tilley, 2008). Account ability as a concept in leadership literature is used for addressing account ability under stress (Bar-Joseph, 2008) and for increasing accountability in bot h employees (Prosen, 2007) and self (Gusky, 2007). Interest in accountability can also be found in public policy reports (Douglas, 2008; Freidman, 2008; Smith, 2000). In nursing, accountability is most often focused on the patient safety movement, with emphasis on error r eduction and quality improvement. This

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29 movement facilitated a change in the focu s of accountability for error, moving from identification of the individual who made the error to an examination of the process leading to the error (Sharpe, 2004) The literature related to patient safety and accountability contains many references to the process of Failure Mode Effects Analysis, defined as a system atic, proactive method for evaluating a process to identify where and how it might fail and to assess the relative impact of different failures in order to identify the parts of the proc ess most in need of change (Institute for Healthcare Impr ovement, 2008). Hospitals accredited by the Joint Commission have adopted this pr oactive process for error reduction (Joint Commission, 2008). However, this model does not address individual professional accountability. Emanuel and Emanuel (1996) offered a model for accountability defined as procedures and processes by which one party provides a justification and is held responsible for its actions by another party that has an interest in the actions (p. 230). Three models of health care accountability are delineated as follows: (a) professional, (b) economic, and (c) political. The professional model guides the physician-patient relationship; while the political model is for the managed care arena. A combined political and economic model mediates the relationship between managed care and the employers who purchase those services. This framework, although purport ed for health care, is heavily medically oriented and ther efore not a good fit for nursing. A review of the nursing lit erature for a nursing fram ework for accountability found that nurses agree that accountability is fundament al to nursing practice

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30 (Rowe, 2000). Others interchange the terms responsibility and accountability (Jormsri, 2005; Maze, 2005; Memarian, 2007). Walsh (1997) advocated for differentiating the terms responsibility and accountability Walsh defined accountability as bei ng able to give an explanation of and justification for ones actions; res ponsibility is carrying out instructions accurately and in the allotted time frame (p.40). Berlandi (2002) also differentiated between accountability and responsibility, defini ng accountability as being answerable and culpable for outcomes and responsibility as being answerable for ones conduct and performance (p.1094). Walsh (1997) explained t hat a registered nurse in the United Kingdom is accountable to the United Kingdom Cent ral Council for Nursing (UKCC), the patient and to self. In t he United Kingdom, the UKCC is both the registering body and professional organization for register ed nurses. In the United States, the counterpart to the UKCC is t he State Board of Nursing in the state in which the registered nurse is licensed. The regist ered nurse is accountable to the state board in which she or he is licensed. Additionally, the American Nurses Association (ANA), the professional association for registered nurses in the United States develop ed and promulgates the Code of Ethics (2001). This code represents the professions non-negotiable ethical standard and outlines the ethical obligations of t he registered nurse. These obligations include the accountability and duties of everyone who enters the profession. Furthermore, the Code of Ethics describes the commitment of nursing to society (Hook & White, 2003).

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31 A discussion about accountability and a code of ethics would not be complete without a brief discussion about ethics. Ethics is a method for understanding and examining the moral life. Ethics provides a way of dealing with the basic questions of meaning and value. There are both philosophic and theological aspects to ethics (Beauc hamp & Childress, 2008; Veatch, 1989). Ethics are normative and non-normative. Normative ethics are concerned with what is generally accepted as mora l behavior and why the behavior is accepted as normal. Practical or applie d ethics is an attempt to use normative principles to solve practical problems. There are two types of non-normative ethics. The first type of non-normative ethics is descripti ve and uses scientific codes to study moral codes and beliefs. Examples woul d be the anthropologis t or sociologist who studies which moral norms are expr essed in professional practice and professional codes. The second type is meta-ethics, which analyze the language, concepts and methods of reasoning in ethics. Non-normative ethics try to establish what is the case, not what ethically ought to be the case, which is called normative ethics (Beauchamp & Childress). According to the United Nations ([UN], 1948), morality refers to norms about what is right or wrong in hum an behavior and interaction. Morality encompasses moral principles, rules, rights, and virtues that are generally accepted norms across all societies. Individuals grow up recognizing and following these norms; if individuals do not follow expected norms, there are consequences. The societal norms for humans are delineated in the United

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32 Nations Declaration of Human Rights signed in 1948. These human rights recognize the individuals right to life, liberty, and security of person (UN). The earliest reference to ethics in nursing was an article comparing ethics and etiquette. Ethics refers to character as etiquette does to manners (Perry, 1907, p. 451). Perry identified ethical qualities of the nur se as obedience, truthfulness, trustworthiness, neatness and punctuality (p. 481). Levine (1977) wrote that nurses need to willingly assume ethical responsibility in every dimension of nursing practice. There has been discussion in the nursing literature (Curtain, 1980; Yarling & McElmurry, 1986) opining that nurses who work in hospital settings are not free to be moral or ethical; although they have freedom of will, ther e is no freedom of action. Action is necessary to assume the ethical responsibility advocated by Levine (1977). According to Curtain (1980) and Yarling and McElmurry (1986) this lack of freedom to act is rooted in the bureaucratic milieu of the hospital, the nurses role in that bureaucracy, the strength of nursing leadership in the system, sexism, and paternalism. The bureaucratic system removes the nurses ability to make nursing decisions about nursing practice. Bishop and Scudder (1987) countered that notion of lack of freedom or autonomy in the bureaucratic system and suggested that teamwork among the physician, nurse, patient, family, and hospital meet the patients needs. They ar gued that the entire team is necessary to morally meet patients needs; it woul d not be a good situation for everyone to be working autonomously. Ketefian (1985) studied professional and bureaucratic

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33 role conception and moral behavior among nurses and found that role conception did influence moral behavior. Historically the ANA has recognized a need to provide a framework to assist registered nurses to make mora l and ethical decisions (Twomey, 1989). The Code of Ethics (ANA, 2001) recognized accountability as an essential behavior and expectation for all nurses. Accountability is defined as "being answerable to oneself and others for one's ow n actions" (p. 16). Accountability is further described as being grounded in the moral principles of fidelity and the respect for the dignity, worth and self-det ermination of all patients. Beauchamp and Childress (2008) identified fidelity as the fundamental ethical principle from which all other principles can be derived. The obligatio n of fidelity or promise keeping is rooted in respect for autonomy and utility. Most oblig ations of positive beneficence in health care rest on fidelitygenerating contracts and role relations (Beauchamp & Childress). In the same code statement as accountability the ANA (2001) Code of Ethics also addressed responsibility. Res ponsibility is the accountability and liability associated with the implementati on of a particular role. The nurse is responsible and accountable for individual nursing practice and the appropriate delegation of tasks to deliver optimum nursing care to patients. Nursing practice includes direct care activities, acts of delegation, and other responsibilities such as teaching, research and administration. In all nursing activities, the nurse retains a ccountability and responsibility for the quality of nursing practice and for confo rmity with standards of care (p 16).

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34 In delivering care, the nurse is acc ountable for determining his or her own ability to implement the care safely and competently. If the care required by the patient is beyond the competence of the nurse he or she must consult someone who is competent and can provide instruction on the optimum way to meet the patients needs. When delegat ing tasks of patient care, the nurse is accountable not only for assessing the competence of the individual to whom he/she is delegating but also for monitoring the i ndividuals activities and evaluating the quality of the care provided. It is not permissible for the nurse to delegate the responsibilities of assessment or evaluation (ANA, 2001). The National Council of State B oards of Nursing (NCSBN, 2007), an organization through which boards of nursing discuss and act on matters of mutual interest and concern, recognize s accountability as a central tenant of nursing practice. In the Principles and Premises of the National Council of State Boards of Nursing website, accountability is descri bed as nurses recognition of their limitations, placing themselves in settings and roles that allow them to practice safely and understanding the need to maintain competence through life long learning. The Council fu rther states that the nurse is responsible and accountable for exhibiting ethical behavior, assuring that client welfare prevails, practicing within the legal limits establis hed for practice, and seeking professional education based on assessed needs. This study was developed around the in tegrity of the medical record and the assumption of truth in documentation in the record. Therefore a search was conducted using medical record, falsif ication and accountability as search

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35 termsno studies were found that looked at falsification of medical records. However, according to the NCSBN, it is misconduct to falsify reports, client documents, agency records or other essential health documents. The Code of Ethics for Nurses statement five refers to ma intenance of integrity and warns against falsification of the medical record. Summary The focus on patient safety thro ugh decreasing errors has changed the hospital environment. By t he nature of their responsib ilities, nurses play an integral role in creating a safe environment for patients w ho are hospitalized. Although the investigation of error cu rrently focuses on processes and not on individuals, the register ed nurses professional Code of Ethics requires individual accountability for decisions and actions regarding patient care. Registered nurses face the challenge of more stri ngent policies designed to create a safe patient environment and, at the same time, they care for patients with very complex needs. The potentia l for conflict between an employers expectations and the professional values held by t he registered nurse is great. When this situation becomes untenable, some registered nurses may misrepresent their actions. Consideration must be given to reconcile the differences between employers expectations as defined in policies and procedures and nursings Code of Ethics Misrepresentation of actions by regi stered nurses has implications for patient safety. If the registered nurse fa ces conflict between wh at the employer expected and what actually happened, t he registered nurse might falsify the

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36 record, thus meeting employer expectati ons but violating their state board of nursings expectations and the Code of Ethics Additionally a falsified medical record does not present an accurate pict ure of the patients medical response and treatment, which has implications for th e patients safety. It would be helpful for hospitals to know if registered nurse s would demonstrate professional values when faced with conflict with patient care A review of the literature revealed descriptive data related to professional va lues held by regist ered nurses but no studies that informed w hether or not registered nurses would act in a professional, accountable manner when fac ed with patient care situations that put them in conflict with hospital policy.

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37 Chapter Three Methods Research Design This study used a descriptive, non-experimental research design. Data were collected and analyzed regardi ng each participants ethical ideology, professional values and intention to act accountably. Ethical ideology was modeled after research using the Ethica l Position Questionnaire (Forsyth, 1981). Ethical ideology is based on relativism and idealism. Relativism and idealism can be further divided into high and low thus forming four groups: (a) absolutists, (b) exceptionists, (c) subjectivists and (d) situationists. The participants were classified according to their self-described ethical ideology and categorized as belonging to one of these four groups. Data from the identific ation of ethical ideology were then analyzed to determine th eir effect on professional values and intention to act accountably. Ethical Considerations Exempted approval was sought and granted by both the University of South Florida (USF) Institutional Review Board (IRB) and the health care system in which the study was conducted. Co mpletion and return of the survey questionnaire implied voluntary cons ent to participate in the study. Confidentiality of the participants was protected, as no identifying data were collected. Data were reported in aggregate format and no information was provided to participants employers.

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38 There were no anticipated physical, psyc hological, or finan cial risks for the participants who participated in the study. No identifying data were collected so it was impossible for the investigator to identify the participant. The investigator, who is employed in a non-managerial role in the health system used in the study, provided a contact number in case the participants had any concerns about the study. Sample and Sampling Procedure The participants for this study were registered nurses employed in a nonprofit health system comprised of four hospi tals, all of which were situated on the west central coast of Florida. This health care system has 1100 licensed beds and employs 900 registered nurse s of which 700 are in direct patient care areas where medications are administered. Prior to data collection, a power a nalysis was completed. A power analysis predicts if there is a strong probability that existing effects have a chance of producing significance. Power is determined by three factors: Significance level, size of treatment effects and sample size (Polit, 1999). For this study, the alpha significance level was set at .05 and Cohens d was set at .50 for a medium effect size. The power analysis set at 80 indicated a need for 64 participants in each of the four cells of the taxonomic groups for a total of 256 participants. Procedure Once the institutional review board approvals were obtained, the investigator contacted all 27 in-patient unit nurse managers in the health care system via email to request access to the study population of registered nurses

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39 during their team meetings. Twenty of the 27 nurse managers responded to the request for access, and the investigator distributed the surveys to registered nurses in all 20 units. This was accomplishe d by the investigator visiting each of the units during scheduled meetings, provid ing a brief overview of the study and distributing the survey ques tionnaires to the register ed nurse attendees. Extra surveys were left on these units for t hose registered nurses not in attendance when the investigator was there. The investigator al so distributed surveys at council meetings attended by registered nurses and at orientations held during the data collection period of May 8 through June 15, 2007. Council meetings are a part of the shared governance structure of the patient services division. In all instances, the participants t ook the surveys with them. Those who completed them returned them to the investigator via self-addressed interoffice envelopes provided by the investigator. This allowed further anonymity for the participants but raised the possibility that individuals might complete more than one survey or that non-registered nurses might have participated in the study. The potential for this over participation or non-registered nurse participation was mitigated by the fact there was no reimbur sement to the parti cipants. Thus, a potential incentive for over participation was removed. Operational Definitions Ethical Ideology consisted of two c oncepts: (a) the degree of relativism (the use of universal moral rules) and (b ) idealism (the belief that good can come of all situations). These characteristics are exhibited by individuals when they

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40 make an ethical decision (Forsyth, 1981). Ethical ideology was operationalized through the Ethical Position Q uestionnaire for this study. Professional values are those values identified in the ANA Code of Ethics with Interpretive Statements (2001). The values express nursings own understanding of its commitment to societ y. The Nurses Professional Values Scale Revised (Shank & Weis, 1989) was used to measure the professional values held by nurses or nursing students for this study. Accountability is a professi onal value found in the ANA Code of Ethics with Interpretive Statements It is defined as being answerable to oneself and others for ones own actions. Accountability in this study was operationalized by the Accountability Instrument. It consisted of two clinical vignettes; the participant answered three 10-point Likert-ty pe questions after each vignette. Instruments Information about Subjects. The face sheet of the survey booklet contained an assurance of anonymity. Thus no identifying data were collected. Survey completion was considered as c onsent to be in the study. Information about participants included the demographic data of age and gender. Additional information garnered included years as a registered nurse and years in their current position. Informati on about religiosity and course work in ethics during nursing education was also gathered. The information about the questionnaire can be found in Appendix A. Ethical Position Questionnaire. The Ethical Position Questionnaire (EPQ) was developed by Forsyth (1981) to help cl assify individuals by their ethical

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41 ideology. The EPQ (Appendix B) consists of 20 items formed from two 10-item scales; one scale measured idealism and the other scale measured relativism. The respondents indicated agreement or di sagreement to the scaled items using a nine-point Likert-type response. A median split was performed on the relativism characteristic to set high versus low re lativism; likewise, a median split was performed on the idealism characteristic to set high or low idealism. This created a two (high idealism x low idealism) by tw o (high relativism x low relativism) configuration. Forsyth ( 1980) reported the mean for the relativism scale was 6.18; the mean for idealism was 6.35. Cronbachs alpha were .73 and .80 respectively. Test-retests were .67 for idealism and.73 for relativism. In this study the alpha coefficients were .80 fo r both the relativism and idealism scale. Nurses Professional Values Scale Revised. The Nurses Professional Values Scale Revised (NPVSR) developed by Weis and Shank (2005) was also administered in this study (Appendix C). The NPVSR consists of 26 items with a five-point Likert-type scale format. It is based on the 2001 Code of Ethics for Nurses. Psychometric properties for the NPVSR have been evaluated but not published. The authors of t he scale provided this researcher with the psychometric properties of the Nurses Professional Values Scale (NPVS) as reported in the next par agraph (personal correspondence from Darlene Weis; October, 2005). The Nurses Professional Values Scale is a 44-item norm referenced instrument with a five-point Likert-type scale format developed to establish the degree to which nurses embrace the tenants of the ANA Code of Ethics The

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42 participants were asked to rate the impor tance of value stat ements drawn from the 2001 Code of Ethics Five judges with expertise in the ANA Code of Ethics provided evidence in support of content va lidity. The reported alpha coefficient for the 44-item NPVS was 94 with a test-retest two weeks later of .94 (Weis & Shank, 2000). Unlike the NPVS, the shortened NPVS Revised contained 26 questions with a potential score range of 26 to130. The alpha coefficient for the NPVSR in this study was .93. Accountability Instrument. The accountability instrum ent (developed by the investigator, see Appendix D) consisted of two hypothetical clinical vignettes designed to represent actual clinical situations in which the registered nurse would have the opportunity to demonstrate accountability. Prior to administration of the survey five registered nurses a ssessed both hypothetical clinical vignettes in the instrument for content validit y. All agreed the clinical vignettes as presented in accountability instrument were realistic. They also reported time used to complete all four surveys as 8 to11 minutes. Because the accountability instrument was investigat or developed, reliability scores were calculated. The alpha coefficient for the accountability inst rument was .74. This met the minimal requirements for internal consistency to be considered sufficient when performing group level comparisons (Polit, 1999). The validity of paper and pencil prof iles has been demonstrated in several studies examining clinical decision making (Fisch, Hammond, Joyce, & Reilly, 1981; Gillis, Lipkin, & Moran, 1981; Holzworth & Wills, 1999; Rothert, 1982; Smith, Gilhooly, & Walker, 2003). To assess instrument validity in this study each

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43 participant was asked to rate on a 10-point Likert-type scale how realistic he or she found the hypothetical clinical situation that was presented. In the first vignette of the a ccountability instrument, there was not a complication for a patient when a nurse erred and did not administer a medication at the prescri bed time. In the second vign ette of the accountability instrument, there was a complication for the patient presumably because a nurse erred and did not administer a medication at the prescribed time. Two vignettes with different outcomes were utilized to measure registered nurses likelihood to act accountably in situations that have opposite outcomes from the same error. In both vignettes, as happens daily in hos pitals, only the nurse knew that the medications were delivered late. The nurse had to decide which time to record on the medication administration: (a) the act ual time or (b) the time dictated by hospital policy. A registered nurse who acts accountably would record the actual time of medication admini stration. With both vignette s the participants were asked how likely they were to record the actual time of medi cation administration, to complete an incident report and to notify the physician. They rated their likelihood on a 10-point Likert-type scale. Data Analysis The raw data were entered into an EXCEL spread sheet and then uploaded into the data manager of Stat istics Package for Social Sciences (SPSS) 11.0. The explore procedure was run to identify outliers. To analyze Hypothesis 1 an analysis of variance wa s run using the MANOVA procedure. The dependent variable for Hypothesis 1 was the mean score on professional

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44 values; the independent variable was ethical ideology. A Pearsons correlation and an analysis of covariance using the MANOVA procedure were run to analyze Hypothesis 2. The dependent variable for Hypothesis 2 was the score on the accountability instrument; the independent variable was ethical ideology and the covariate was professional values. Summary This chapter presented the st udy design and information about the instruments used in the study. The follo wing chapter reports the analyzed results of the study.

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45 Chapter Four RESULTS A sample of 215 registered nurses employ ed at a four-hospital health care system on the west coast of Florida voluntarily participated in this descriptive study. This chapter presents information about the study sample, data collection methods, procedures and data analysis. Th e results of the two hypotheses testing are also included. Data Collection Data collection took place from May 8 through June 15, 2007 after distributing the surveys at inpatient uni ts and at council meet ings at a fourhospital health care system on the west c oast of Florida. There were 475 surveys distributed, and 219 were returned (46% re turn rate). This fell short of the proposed sample size of 256 in the power analysis. The investigator stopped at that number because all avenues for distri bution of the survey had been explored and no additional surveys had been retur ned in more than one week. Four surveys were discarded because the Nurses Professional Values Scale Revised (NPVSR) was not completed; thus t he analysis was based on 215 surveys. Preliminary Statistics In the remaining 215 data sets, missing data on the Ethical Position Questionnaire by using a neither agree or disagree response and therefore the 17 missing values were scored as a 5 on the 1 to 10 scale. There were no missing data for the Professional Values scale. The four missing data points for

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46 the accountability instrument were replac ed by mean substitution for that scale ( M = 41.36). Next, the explore proc edure was run to identify outliers. Demographic data on the study samp le are presented as frequencies and descriptive statistics in Table 3. There were 195 female and 19 male respondents. The age range was 23 to 68 years with a mean age of 44.6 years. The nurses reported a range of less than one month to 49 years experience as a registered nurse with an aver age of 5.16 years in thei r current registered nurse (RN) position. On average the sample wa s 45 years old, female, with either an associate or bachelors degree in nursing, 17 years of nursing experience and 5 years of employment in their current position. Seventy si x percent reported having had an ethics class and 79 % percent had studied the ANA Code of Ethics in their nursing program. The majority of respondents were Caucasian (85%) followed by Asian Pacific (7%), Hispanic (6%) and African Am erican (5%). This larger percentage of Asian Pacific respondents is somewhat at ypical for the west coast of Florida and may have resulted from heavy recruitment in the Philippines that occurred in 2005 for that hospital setting.

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47 Table 3 Demographic Data on Study Sample Item n Percentage Age 60-69 14 6% 50-59 72 34% 40-49 56 27% 30-39 39 19% 20-29 28 14% Total 209 100% Ethnicity Caucasian 179 84% Asian Pacific 15 7% Hispanic 8 6% African American 7 4% Total 215 100% Highest Level of Nursing Education Diploma 13 6% Associate 75 34% Baccalaureate 85 40% Masters 42 20% Total 215 100%

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48 Table 3 (Continued) Item n Percentage Gender Female 195 91% Male 19 9% Total 214 100% Ethics Ethics Course 163 76% Studied ANA Code of Ethics 170 79% Descriptive statistics of key vari ables are found in Table 4. The professional values scores for this study ranged from 74 to 130 with a mean of 108.53 (from a possible range of 26 to 130). For accountability, scores for this study ranged from 20 to 60 with a mean score of 41.36 (from a possible range of 6 to 60). Religiosity demonstrated the full range of potential scores of 1 to 10. The mean religiosity score was 5.80. Table 4 Summary Descriptives of Continuous Variables Item n Mean Standard Deviation Minimum Maximum Age 209 44.60 11.06 23 68 Professional Values 215 108.53 12.22 74 130 Accountability 215 41.36 10.71 20 60 Religiosity 215 5.80 2.28 1 10

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49 Prior to testing Hypothesis 1 and 2, correlation coefficients (Table 5) were run to determine if variables were mutually exclusive or related. No significant relationships were found between ethical ideology and accountability. However, significant relationships were found betwe en ethical ideology and professional values. Specifically there was a signifi cant positive relationship between idealism and professional values and a negative non-significant relationship between relativism and professional values. This relationship was further evaluated in Hypothesis 1. A significant relationshi p was also found between professional values and accountability (r = .354, p < .001). These findings affected how Hypothesis 2 was evaluated. Age, religio sity, and years as a registered nurse were also positively correlated with a ccountability, and were later evaluated as covariates. Table 5 Correlation Coefficients Accountability Professional Values Idealism Relativism Age Religiosity Years RN Accountability Professional Values a .354 ** Idealism b .108* .115* Relativism b -.056 -.053 .062 Age a .277** .101 -.051 -.275** Religiosity a .182** .191** .033 -.147* .000. Years RN a .207** .100 -.094 -.121 ..684 .095 Note. a Pearsons r ; b Kendall's tau b.* Significant at .05 al pha level ** significant at .01 alpha level

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50 A small, negative and insignificant correlation was found between relativism and accountability, while a larger negative correlation had been expected. Therefore a decision was made to examine the sub-components of relativism and idealism (absolutists, exceptio nists, situationists and subjectivists) separately with accountability. Bivari ate correlations between the dependent variable (accountability) and each of t he key independent variables were done separately. First, bivariate correlations for the accountability scores with the four groups of ethical taxonomy were done. As seen in Table 6, these revealed that only absolutists had a significant relations hip with total accountability scores. The other bivariate relationships were of negative direction and non-significant. Within the low relativism component of the ethical taxonomy, represented by both the absolutists and the exceptionists, there was a moderate and significant inverse relationship between the absolutists and exceptionists. Within the high relativism component of the ethical taxo nomy, represented by the situationists and the subjectivists, ther e was a moderate and significant inverse relationship between the situationist s and the subjectivists.

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51 Table 6 Bivariate Correlations for Accountabili ty by Ethical Taxonomy (N = 215) Accountability Absolutist a Exceptionist a Situationist b Subjectivist b Accountability Absolutist a 0.145* Exceptionist a -0.027 -0.343** Situationist b -0.024 -0.330** -0.299** Subjectivist b -0.097 -0.369** -0.335** -0.322** Note. a Relativist Category b Idealist Category Significant at .05 alpha level ** Significant at .01 alpha level Prior to testing Hypothesis 1 and Hypothesis 2, reliability tests were completed on the investigator-devel oped accountability instrument. The instrument consisted of three questions that parti cipants answered immediately after reading two different clinical vignettes involving a late administration of a medication. In both clinical vignettes the participant was asked how likely on a 10-point Likert-type scale they were to record the actual time of medication administration, complete an incident r eport, and notify the physician. The alpha coefficient for the accountabi lity instrument was .74. Inter-item correlations were conducted among the six items (see Table 7). Additionally after each vignette was presented, the respondents were asked, on a 10-point Likert-type scale of how realistic they found the vignettes. Scores for this question could range from 2 to 20. Mean score for this study wa s 16.10 indicating that the respondents found the vignettes very to extremely realistic.

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52 Consistency was observed in the manner in which participants responded to the three questions follo wing each of the two vignettes (see Table 7). The correlation between the time documented question in each vignette was strong ( r = .94), as was the correlation between the call physician question in each vignette (r = .85). The correlation between completing the incident report question in each vignette was weaker ( r = .43). The latter results suggest that in the presence of a complication, registered nurses reacted differently than if there was not a complication. According to Polit (1999), reliabilities are best if at least .70 or above; thus, 2 out of 3 questions were above this suggested value. No reverse scoring was needed for any of the items. Table 7 Inter-Item Reliability Coefficients Time Document 1 Call Phys 1 Incident Report 1 Time Document 2 Call Phys 2 Incident Report 2 Time Documented 1 Call Physician 1 .034 Incident Report 1 -.034 .774* Time Documented 2 938* .016 -.071 Call Physician 2 -.024 .852* .721* -.008 Incident Report 2 0369 .334* .432* 062 .385* Note: 1 Response after 1 st vignette. 2 Response after 2 nd vignette. Significant at .01 Hypothesis 1 Hypothesis 1 stated that registered nurses who demonstrated a low relativistic (absolutist or exceptionist ) ethical ideology would score higher on a

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53 measure of professional values than would registered nurses who demonstrated a high relativistic (situationist or subjec tivist) ethical ideol ogy. Referring to Figure 1 on page 7, recall that ethical ideology was conceptualized as having a direct effect on professional values. The high versus low relativists were targeted for this hypothesis; however all four subgr oups of the ethical ideology taxonomy were included (situationists, subjectivists, exceptionists, and absolutists). This was necessary to do the MANOVA procedure. In order to evaluate Hypothesis 1, par ticipants first had to be classified as low relativists or high relativists and as low idealists or high idealists. The scores on the two subscales (relativism and idea lism) of ethical ideology were first computed. A median split wa s performed to form the groups of high versus low relativists and of high versus low idealists Relativism scores ranged from 10 to 90 with a median score of 50 ( M = 52.09, SD = 16.49). Therefore, scores of 50 and below on the relativism scale were cla ssified as low relativists; scores of 51 and above were classified as high relati vists. Idealism scores ranged from 22 to 90 with a median score of 73 ( M = 70.80, SD = 13.87). Therefore any scores 73 and below were considered low idealists; scores of 74 and above were classified as high idealists. Thus the two groups, relativists and idealists, were each subdivided into high or low relativists or i dealists. The low relativists consisted of absolutists (n = 59) and exceptionists ( n = 51). The high relativists consisted of situationists ( n = 48) and subjectivists ( n = 51). Scores on the Nurses Professional Values Scale Revised were then computed. The scores r anged from 74 to 130 ( M = 108.43, SD = 12.16). Table 8

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54 illustrates the mean values of the prof essional values scores according to the relativism group classifications. The ma rginal mean for the professional value score for the low relativists (M = 110.19) was higher then the marginal mean for the professional value score for the high relativists ( M = 106.78). This was in the predicted order that RNs who were low relativists would score higher on this measure of professional values than would the RNs who were high relativists. In contrast, those participants who were high idealists had higher marginal mean scores ( M = 111.37) on professional values t han did those who were low idealists ( M = 105.72). This finding is explored furt her in the analysis of Hypothesis 2. Table 8 Group and Marginal Means of Professional Values Scores by Ethical Taxonomy High Relativism Low Relativism Marginal Means High Idealism Situationist N = 48 M = 110.23 SD = 12.26 Absolutist N = 59 M = 112.29 SD = 10.49 111.37 Low Idealism Subjectivist N = 57 M = 103.88 SD = 12.64 Exceptionist N = 51 M = 107.77 SD = 12.09 105.72 Marginal Means 106.78 110.19

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55 Next, a 2 x 2 analysis of varianc e was conducted using the MANOVA procedure, with relativism (high and low) and idealism (high and low) as independent variables and the Nurses Prof essional Values Scale Revised scores as the dependent variable. The results ar e illustrated in Table 9. As noted previously, examination of the marginal means for the low versus high relativists showed that the low relativists had higher marginal means than did the high relativists. The main effect of relativism on professiona l values was not significant ( p = .07). Therefore Hypothesis 1 was not supported. However the main effect of idealism on professional values was significant ( p = .001). Additionally there was no significant interaction between the independent variables ( p = .57), meaning that relativism and idealism were indep endent of each other. The values for accountability were consistent across all le vels of relativism and across all levels of idealism. Table 9 Analysis of Variance of Nurses Prof essional Values by Ethical Ideology Source df MS F 2 p Within Cells 211 140.80 Relativism 1 471.89 3.35 .02 .07 Idealism 1 1578.38 11.42 .05 .001 Relativism x Idealism 1 44.62 .59 .002 .57

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56 Hypothesis 2 Hypothesis 2 stated that absolutists are more likely to act accountably in hypothetical clinical situations than exceptionists. Exceptionists are more likely to act accountably than are subjectivists and subjectivists are more likely to act accountably than are situationists. Recall that in Figure 1 (page 7) et hical ideology was depicted as having both a direct effect and an indirect effect on accountability. To test Hypothesis 2, several different procedures were used; first, a descriptive summary was used to analyze the ordered means of the total accountability scores by ethical taxonomy group. Then an ANCOVA using the MANO VA procedure was used to analyze the total accountability scores as the dependent variable. And finally, the accountability questions were examined individually to see if any of their effects were masked by being bundled into a composite accountability score. Potential scores ranged from 1 to 10 on each item; the total score could range from 6 to 60 on the six-question acc ountability instrument. Individuals who answered at least a very likely and extremely likely ( a score of 7 out of 10 possible on that item) in response to a ll six accountability questions and who thus scored a minimum of 42 to 60 were c onsidered to be accountable. The responses of very likely and extremely likely were chosen to indicate accountability as these were the highest two categories on the scale and were above the median. Actual accountability scores ranged from 20 to 60 with 60 being the most frequent score (frequency = 18); the mean score was 41.36 ( SD = 10.71).There

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57 were 103 (48%) of the respondents w ho scored in the range 42 to 60 on the accountability instrument and were t herefore considered accountable. The means and standard deviations for each of the taxonomic groups of ethical ideology on the a ccountability instrument are presented in Table 10. As predicted, the absolutists had higher mean accountability scores than did the exceptionists. Likewise, the exceptioni sts had higher mean accountability than did the subjectivists. However, contrary to prediction, the subjectivists did not have higher accountability than the situationists. Table 10 Group and Marginal Means of Accountability Scores by Ethical Taxonomy High Relativism Low Relativism Marginal Means High Idealism Situationist N = 48 M = 40.68 SD = 10.34 Absolutist N = 59 M = 44.29 SD = 10.82 42.67 Low Idealism Subjectivist N = 57 M = 39.59 SD = 10.55 Exceptionist N = 51 M = 40.60 SD = 10.75 40.07 Marginal Means 40.09 42.58

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58 The next task was to complete t he ANCOVA with the four taxonomic groups of the ethical ideology (absolutis ts, exceptionists, situationists, and subjectivists) as the independent variabl e, accountability as the independent variable and professional values as the covariate for this ANCOVA procedure. The ANCOVA helped clarify the indirect and direct effects of et hical ideology on accountability for Figure 1. Results of the analysis of covariance are found in Table 11. Table 11 Analysis of Covariance of Accountability by Ethical Ideolo gy with Professional Values as Covariate Source df MS F 2 p Within Cells 210 100.95 Professional Values a 1 2617.95 25.93 .11 .000 Idealism b 1 30.36 .30 .001 .584 Relativism b 1 107.27 1.06 .01 .304 Idealism X Relativism 1 131.84 1.30 .01 .255 Note a Covariate variable = Professional Values b Independent variables After controlling for in the effect of Professional Values, the adjusted means (Table 12) were in the predicted order; however, since the test of significance for the differences among those means was still not significant, Hypothesis 2 was still not supported completely.

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59 Table 12 Adjusted Group and Marginal Means of Acc ountability Scores by Ethical Ideology with Professional Values as Covariate High Relativism Low Relativism Marginal Means High Idealism Situationist N = 48 M = 40.18 Absolutist N = 59 M = 43.18 41.83 Low Idealism Subjectivist N = 57 M = 40.97 Exceptionist N = 51 M = 40.83 40.91 Marginal Means 40.61 42.09 After the original descriptive su mmary and ANCOVA were completed a decision was made to examine the data fo r a monotonic trend, which is a less stringent measure of detecting differ ences among means (Abelson & Tukey, (1963). The monotonic trend would indica te whether or not there was an increasing order for all f our ethical ideologies when compared to the total accountability scores. The analysis fo r monotonic tend was completed on the analysis of covariance with the accountabi lity scores. The results of the analysis for monotonic trend can be found in T able 13. There was no support for a monotonic trend.

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60 Table 13 Monotonic Trend Analysis Accountability Instrument Source df SS MT MS error F p ANCOVA 1, 210 8.116 105.57 .076 >.05 Due to the significant correlation among accountability, religion and age (see Table 5) and their potential to be confounding variables, an analysis of covariance using the MANOVA procedure wa s performed. Accountability was the dependent variable, ethical taxonomy wa s the independent variable and age and religion were covariates. After contro lling for age and religion no significant differences among means for accountability by ethical taxonomy were found. Finally, after completing the descriptive summaries, the ANCOVA procedures and the monotonic trend analysis on the entire accountability total score, the decision was made to separatel y analyze each of the three questions of the accountability instrument across t he two vignettes. This was done in case the individual differences were masked by using a composite total score for accountability. To complete the analysis of Hypothes is 2, a series of analyses were performed. The analysis of their ordered means was done by individual question, one at a time, next an analysis of cova riance using the MANOVA procedure was performed on each of the individual questions of the accountabilit y instrument, using the NPVSR as the covariate and the ethical ideology group as the independent variable.

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61 Scores on the individual question s for the two vignettes of the accountability instrument may range from 2 to 20. As in the case when considering the entire accountability instrument, individuals who answered very likely and extremely likely in response to the individual accountability questions and who scored a minimum of 14 to 20 were considered to be accountable. The responses of very likely and extremely likely were chosen to indicate accountability as these were the highes t two categories on the scale and were above the median. The descriptive summa ry is given first, followed by the ANCOVA for each of the three accountability domains. First, the accountability score for reporting the correct time of medication administration was analyzed (Question 1). Respondents accountability scores for time of administration across both vi gnettes ranged from 2 to 20 with 20 being the most frequent score (frequency = 111); the mean score was 17.59 ( SD = 4.12). There were 201 (93%) of the re spondents who scored in the range 14 to 20 on Question 1 of the accountability inst rument and were therefore considered accountable regarding documenting the actual time of administration. Respondents accountability scores fo r Question 2 (calling the physician) across both vignettes ranged from 2 to 20 with 20 being the mo st frequent score (frequency = 31). There were 80 (37%) of the respondents who scored in the 14 to 20 range on Question 2 of the account ability instrument and were therefore considered accountable with regard to calling the physician. Accountability scores for Question 3 (completing an incident report) ranged from 2 to 20 with 20 being the most frequent score (frequency = 26).

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62 There were 89 (41%) respondents who scor ed in the 14 to 20 range on Question 3 of the accountability instrument and we re therefore considered accountable with regard to completing an incident repor t. Thus for the descriptive summary for each individual accountability questi on, 93% of the nur ses reported being accountable for documenting the correct time of medication administration, while only 34% reported calling the physician an d 41% completing an incident report. The ordered means resulting from t he ANCOVA can be found in Table 14. As illustrated in Table 14 there are two unique orders of means among the three possible orders. With time of administration the order of means was as predicted; absolutists scored higher than exceptioni sts; exceptionists scored higher than subjectivists and subjectivists scored hi gher than situationists. For the two remaining items in Table 14, calling the physician and completing an incident report the orders of means were identical; however, these orders were not as predicted.

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63 Table 14 Means of Individual Questions of Account ability Instrument by Ethical Ideology with Professional Values as a Covariate High Relativism Low Relativism Situationist N = 48 Absolutist N = 59 M = 17.19 M = 18.09 High Idealism SD = 4.53 SD = 3.95 Subjectivist N = 57 Exceptionist N = 51 M = 17.46 M = 17.55 Question 1 (Record Time) Low Idealism SD = 3.46 SD = 4.61 Situationist N = 48 Absolutist N = 59 M = 11.02 M = 12.31 High Idealism SD = 5.74 SD = 6.30 Subjectivist N = 57 Exceptionist N = 51 M = 10.32 M = 10.57 Question 2 (Call Physician) Low Idealism SD = 5.81 SD = 6.14

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64 Table 14 (Continued) High Relativism Low Relativism Situationist N = 48 Absolutist N = 59 M = 12.49 M = 13.95 High Idealism SD = 4.69 SD = 4.35 Subjectivist N = 57 Exceptionist N = 51 M = 11.82 M = 12.45 Question 3 (Complete Report) Low Idealism SD = 4.72 SD = 5.21 Finally, the individual questions we re analyzed by ANCOVA. As seen in Table 15, there were not any signific ant effects for the independent variable (ideology group) after controlling for the ma in effect of the covariate (Nurses Professional Values Scale Revised). The potential effect of the covariate nurses professional values will be explored in Chapter 5.

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65 Table 15 Analysis of Covariance of Individual A ccountability Questions by Ethical Ideology with Professional Values as Covariate Source df MS F 2 p Question 1 (Record Time) a Within Cells 210 17.14 Professional Values 1 1.75 .10 .00048 .750 Idealism 1 1.56 .09 .00043 .763 Relativism 1 14.09 .82 .00390 .366 Idealism X Relativism 1 8.32 .49 .00231 .487 Question 2 (Call Physician) b Within Cells 210 32.83 Professional Values 1 732.19 22.30 .09601 .000 Idealism 1 6.81 .21 .00099 .649 Relativism 1 4.71 .14 .00068 .705 Idealism X Relativism 1 23.21 .71 .00336 .401 Question 3 (Complete Report) c Within Cells 210 19.67 Professional Values 1 608.95 30.96 .12850 .000 Idealism 1 4.85 .25 .00117 .620 Relativism 1 20.17 1.03 .00486 .312 Idealism X Relativism 1 15.61 .79 .00376 .374 Follow up Significant Analyses Hypothesis 1. After noting the significant re lationship between religiosity and professional values, a decision was m ade to further explore the effect of idealism and relativism on professional values while controlling for religiosity. An

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66 analysis of covariance using a MA NOVA procedure was performed with relativism and idealism as the independent va riables, religiosity as the covariate and professional values as the dependent variable. Table 16 Group Means and Marginal Means for Prof essional Values by Ethical Ideology with Religiosity as Covariate High Relativism Low Relativism Marginal Means High Idealism Situationist N = 48 M = 110.23 SD = 12.26 Absolutist N = 59 M = 112.29 SD = 10.49 111.87 Low Idealism Subjectivist N = 57 M = 103.88 SD = 12.64 Exceptionist N = 51 M = 107.77 SD = 12.09 105.57 Marginal Means 106.70 110.62 Table 16 illustrates the mean values of the professional values scores according to the taxonomic group classifi cations while controlling for religiosity. The marginal mean for the professional value score for the low relativists ( M = 110.62) was higher then the marginal mean for the professional value score for the high relativists ( M = 106.70). The results were in the hypothesized direction

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67 that RNs who were low relativists would score higher on a measure of professional values than would the RNs who were high relativists. These marginal means were corroborated by t he results from the MANOVA procedure. In contrast, those participants who were hi gh idealists had higher marginal mean scores ( M = 111.37) on professional values t han did those who were low idealists ( M = 105.72). Next, a 2 x 2 analysis of variance was conducted using the MANOVA procedure, with relativism and idealism as independent variables, the Nurses Professional Values Scale Revi sed scores as the dependent variable and religiosity as the covariate. The resu lts are illustrated on Table 17. The main effect of relativism on professional values was not significant ( p = .12). However the main effect of idealism on prof essional values was significant ( p = .002). There was no interaction between the independent variables.

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68 Table 17 Analysis of Covariance of Professional Valu es by Ethical Ideology with Religiosity as Covariate Source df MS F 2 p Within Cells 210 138.11 Religiosity 1 704.46 5.10 .02 .03 Relativism 1 340.03 2.46 .01 .12 Idealism 1 1329.45 9.63 .04 .002 Relativism x Idealism 1 21.51 0.16 .001 .69 This section explored the main effe ct of relativism and idealism on professional values after controlling for t he effect of religios ity. The marginal means for low relativists were in the pr edicted direction; however the test of significance revealed it was idealism and not relativism that had a significant effect on professional values when controlling for religiosity. Hypothesis 2. The strong correlation among accountability, idealism, age ( r =.28, p < .01), religiosity (r = .18, p < .01) and years as a registered nurse (r = .217, p < .01) prompted further analysis in follow-up testing for Hypothesis 2. Therefore an analysis of covariance on each question of the accountability instrument using the MA NOVA procedure was run with age, religiosity and years as a registered nurse as covariates, a ccountability as the dependent variable and ethical ideology (relativism, idealism) as the independent variable. Tables 18 to 20 show the marginal means of the ethical taxonomy groups for each of the three questions of the accountability instrument with age as the

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69 covariate. For Question 1 the means were in the following order: Absolutists, exceptionists, subjectivists and finally si tuationists. For Q uestions 2 and 3, the descending order was different than for Question 1; absolutists scored highest, followed by situationists, except ionists and then subjectivists. Table 18 Means and Marginal Means for Accountabi lity Question 1 by Relativism/Idealism after Controlling for Age Question 1 (Record Time) a High Relativism Low Relativism Marginal Means High Idealism Situationist N = 47 M = 17.13 SD = 4.56 Absolutist N = 58 M = 18.053 SD = 3.98 17.64 Low Idealism Subjectivist N = 55 M = 17.36 SD = 3.49 Exceptionist N = 49 M = 17.49 SD = 4.69 17.42 Marginal Means 17.26 17.80

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70 Table 19 Means and Marginal Means for Accountab ility Question 2 by Relativism/Idealism after Controlling for Age Question 2 (Call Physician) a High Relativism Low Relativism Marginal Means High Idealism Situationist N = 47 M = 11.00 SD = 5.80 Absolutist N = 58 M = 12.31 SD= 6.36 11.72 Low Idealism Subjectivist N = 55 M = 10.06 SD = 5.75 Exceptionist N = 49 M = 10.43 SD = 6.21 10.23 Marginal Means 10.49 11.45

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71 Table 20 Means and Marginal Means for Accountabi lity Question 3 by Relativism/Idealism after Controlling for Age Question 3 (Complete Form) High Relativism Low Relativism Marginal Means High Idealism Situationist N = 47 M = 12.70 SD = 4.74 Absolutist N = 58 M = 14.02 SD = 4.36 13.43 Low Idealism Subjectivist N = 55 M = 11.61 SD = 4.68 Exceptionist N = 49 M = 12.47 SD = 5.06 11.96 Marginal Means 12.11 13.31 12.70 a Question 3 asks how likely are you to complete an incident report? Although the order of m eans for Question 1 (Table 18) was as predicted, the order of means for Question 2 (Tabl e 19) and Question 3 (Table 20) were not as predicted. Instead, the absolutis ts scored highest, followed by the situationists, the exceptionists, and then the subjectivists. The tests of significance for each of the three questions of the accountability instrument while controlling for age are shown in Table 21. Even though relativism did not produce a significant main effect for any of t he three questions, i dealism did produce a

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72 significant main effect on the Question 3, which was the decision to complete an incident report ( F [1, 204] = 4.83, p =.03). Table 21 Individual Accountabi lity Questions by Relativism/Idealism with Age as Covariate Question 1 (Record Time) df MS F 2 p Within Cells 204 17.39 Age 1 21.39 1.23 .006 .269 Relativism 1 24.41 1.40 .007 .238 Idealism 1 .98 0.06 .000 .813 Relativism X Idealism 1 6.69 0.38 .002 .536 Question 2 (Call Physician) df MS F 2 p Within Cells 204 33.50 Age 1 650.77 19.42 .087 .000 Relativism 1 2.11 0.6 .000 .802 Idealism 1 125.21 3.74 .018 .055 Relativism X Idealism 1 24.21 0.72 .004 .396 Question 3 (Complete Incident Report) df MS F 2 p Within Cells 204 20.20 Age 1 385.47 19.08 .086 .000 Relativism 1 5.38 0.27 .001 .606 Idealism 1 97.66 4.83 .023 .029 Relativism X Idealism 1 10.46 6.87 .003 .473

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73 The analysis of covariance using t he MANOVA procedure was completed with ethical ideology as the independent variable, the indi vidual questions of the accountability instrument as the dependent variables, and religiosity and years of experience as a registered nurse as the covariates. This analysis produced no significant main effects. This section explored each of the three accountability questions to establish the main effects of relati vism and idealism on accountability when controlling for age, religiosity and years of experience as a registered nurse. When controlling for age, Question 1 di d produce the predict ed order of means; however relativism did not have a signifi cant main effect on the taxonomic group order. There was no significant main effect for Question 2. For Question 3 (completing an incident report), idealism did have a significant main effect on taxonomic order. Religiosit y and years of experience as a registered nurse had no significant main effect on any of the questions on the accountability instrument. Summary The data were analyzed to test two hypotheses: 1. Registered nurses who demons trate a low relativistic ( absolutist or exceptionist ) ethical ideology would score higher on a measure of professional values than would regist ered nurses who demonstrate a high relativistic (situationist or subjectivist) ethical ideology. 2. Absolutists are more likely to ac t accountably in hypothetical clinical situations than exceptionists. Exc eptionists are more likely to act

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74 accountably than are subjec tivists and subjectivists are more likely to act accountably than are situationists. For Hypothesis 1, the investigator found that although the means for low relativists were in the predicted direct ion, Hypothesis 1 was not supported as there was not a significant difference between the marginal means of low relativists and high relativists. In contrast, idealism did have a significant main effect on a measure of professional values Additionally there was no support for Hypothesis 2. In Hypothesis 2, the order of taxonomic means (absolutist, exceptionist, subjectivist and situationi st) on the accountability instrument was not as predicted. Each question on the a ccountability instrument was examined separately in case the individual diffe rences among the three questions were masked by using a composite total score for accountability, While time of administration did produce the predicted order of ta xonomic means, ethical ideology did not have a significant effe ct on documenting the actual time of medication administration ( p = .68). However, when controlling for the effect of age, ethical ideology did have a significant effect on completing an incident report ( p = .03). However the significant main effect was for idealism and not the hypothesized relativism. After controlling for religiosity and years of experience as a registered nurse, ethical ideology had no significant main effect on this measure of accountability. Lastly, once the linkage between ethical ideology and nurses professional values was established, the investigator decided to explore Nurses Professional Values with the components of ethical ideology (relativism and idealism) and with

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75 religiosity as a covariate. This was done because religiosity had a significant correlation with a measure of professional values ( r = .19, p = .01). The results with the covariates were similar to those results of the original analysis without any covariates; a significant main effect of idealism was found even when religiosity was controlled. In summary, two hypotheses were tested. In the first hypothesis, a link was established between nurses professional values and ethical ideology; however the hypothesized effect was not signific ant. Therefore there was no support for Hypothesis 1. In the second hypothesis the ordering of the taxonomic means was demonstrated to be different from that which was hypothesized and there were no significant differences in account ability scores by taxonomic groups. The correlation between ethical taxonomy and accountability prompted the researcher to do additional analyses on the differences of group means (relativism or idealism) in accountability scores. When age was controlled, ethical ideology (specifically idealism) did have a significant effect on completion of an incident report. Controlling for religiosity and years of experience as a registered nurse revealed no significant effect of et hical ideology on any of the questions on the accountability instrument. Chapter 5 pr esents the limitations, implications for nursing and recommendations for future research t hat emerged from this research.

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76 Chapter Five Discussion Introduction This study was undertaken to identify the influence of ethical ideology and professional values on registered nurse s intentions to act accountably. The study was important because there is limited research on how registered nurses demonstrate the values they purport to hold. Study results have shown that nurses may misrepresent their actions when they feel a conflict between their values and the requirements of their work environment (Grover, 1993a, 1993b). This investigator wished to determine if ethical ideology and professional values would influence nurses reports of how they would respond to two hypothetical, yet realistic, clinical vignettes. In t he clinical vignettes, the registered nurses should have reported they would document the actual administration time when a medication was given late. This would hav e put the registered nurse in conflict with facility policy. These two vignettes created a moral dilemma for the nurses by forcing them to choose between doc umenting the actual time versus the scheduled time of medication administrat ion. Whether to uphold professional universal moral principles are the types of decisions nurses often face, and this research highlighted t he discrepancy between the Code of Ethics and the moral conduct of nurses.

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77 This chapter focuses on the interpre tation, limitations and implications related to the results obtained from th is study. Recommendations for future research are presented. Discussion Professional values and accountabili ty were each major components of the model. These two factors will be discussed separately, starting with professional values. This study evaluated a relationship bet ween a registered nurses ethical ideology and a measure of professiona l values. Registered nurses who were classified as low relativists (who thus use universal moral principles for decision making) scored higher on a measure of professional values than did highly relativistic registered nurses (who do not use universal moral principles for decision making). However the difference between the scores of high relativists and low relativists was not significant. In c ontrast the effect of idealism did have a significant effect on a measure of prof essional values. This indicated that registered nurses do not necessarily make decisions based on ethical principles but rather on the concept of how much good can be realized from the decision. Ketefian (1982b) found a significant direct correlation between moral reasoning and valuing moral behavior when faced with a nursing dilemma. This study builds upon Ketefians work by correlating nurses types of moral reasoning, defined by their ethical ideol ogy, with their professional values. Professional values build upon pers onal values developed from ones life experiences (Bjorkstrom, 2007; Horton, 2007). Personal values may include

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78 religiosity, honesty and altruism (ONeil, 1973; Thurston et al., 1989; Williams, 1978). Although it was not the primary focu s of this research the demographics showed that the mean score for religiosity was 5.9 on a 10-point Likert-type scale. Furthermore there was a dire ct correlation between religiosity and professional values. This partially supports the studies done by Horton and Bjorkstrom. Personal values also include honesty, responsibility and intelligence (Rassin, 2008). According to the theorie s of moral development by Dewey (as cited by Archambault, 1964), Piaget (as cited by Ketefian, 1981a), Kohlberg (1981) and Gilligan (1977), the development of moral values is associated with maturation of age as well as maturation of cognitive knowledge. The relationship between ages, years of experience as a registered nurse and nurses professional values was not significant. Thus, this study did not support previous findings of maturation of age or years of experience and moral development. There were three measures of accountability in this study: (a) documentation of correct time, (b) notification of the physician, and (c) completion of an incident r eport. Even though the prior st udies indicated that the nurses value accountability and integrity as being fundamental to their nursing practice (Rowe, 2000; Schank & Weis, 1989; Thurston, et al., 1989), actual translation of that belief into practice did not consistently happen in this study. The bridge between values and actual accountability actions needs further exploration.

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79 Self-disclosure may have had an impac t on some of the findings. The commonly held belief that medication e rrors are under reported (Food and Drug Administration [FDA], 2008) was supported in this study. Only 34% of respondents indicated they were very likely or extremely likely to complete an incident report after a medication error. However, despite the hospital administration of the health care system stating there is a non-punitive reporting policy already in place, the name of t he individual who completes an incident report is recorded. The necessity to self -identify as the completer of the incident report may have influenced the participants willingness to report a medication incident. The need to self-identify when calling the physician to report a medication error also may have influenced t he participants willingness to notify a physician when a medication was late. Even though this study did indicate that a nurses ethical ideology impacted their professional values (Hypothesis 1), this research did not support the theories of Forsyth (1980; 1981; 1985) or of Forsyth and Pope (1984) that ethical decision making is based on ethical ideology (Hypothesis 2). After controlling for nurses professional values there was not a significant effect on accountability added by ethical ideology. Furthermore, despite nursing educators values of integrity (Thurston et al., 1989) and despite congruence betw een educators values and student nurses values (Redman, 1966; Thurston & O Neill, 1975), this study showed that after graduation, nurses may not always act accountably or with integrity. However for some of the nur ses, the issue might not hav e been one of integrity;

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80 instead, some of the nurses might not have even recognized that the vignettes were presenting errors. If they did not env ision the vignettes as errors, they might not have seen any reason to self-disclose by reporting the incident or by calling the physician. Significance of Findings This is the first study to examine t he effect of registered nurses ethical ideology on professional values and their intentions to act accountably. Previous studies explored the personality traits (Bailey & Klaus, 1969; Grossack, 1957; Levitt, Lubin, & Zuckerman, 1962; Redden & Sc ales, 1961; Schulz, 1965; Smith, 1968; Stein, 1969), personal values (Durst an, 1964; Garvin & Boyle, 1985; May & Ilardi, 1970; ONeill, 1973; Redman, 1966), and professional values (Eddy 1994; Eddy, Elfrink, Weis & Shank, 1994; Elfrink,1991; Kelly, 1991,1992; Martin, Yarbrough & Alfred, 2003; Shank & Weiss,1989) as characteristics of registered nurses and nursing students. However, none of these previous studies attempted to link intention to act with the personality traits, personal values, or professional values that characterized nurses. In light of the current emphasis on patient safety and error prevention, and with policies and procedures requiring error reporting so that processes lead ing to errors may be studied, it was surprising that the literature contained no studies that supported mandatory reporting of error as a means to decrease errors. A dditionally there were no studies that examined falsification of the medical record. This identified gap in the literature lead to the development of t his study around the integrit y of the medical record and the assumption of truth in documentation in the record.

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81 Implications Based on these findings, the hospital administrators in the health care system in the study should develop a definitively non-punitive error reporting system that forgoes collecting names of registered nurses who complete an incident report for a medication erro r (Peshek, 2004; Potylycki et al., 2006; Stump, 2000; U, 2001). T he Institute on Hospital Improvement ([IHI], 2008a, 2008b, 2008c) provides examples of non-puni tive policies on their website. In addition, orientation programs and classes should include information on the non-punitive environment for reporting medi cation errors. Time should be spent discussing the advantages of reporting late medications and other medication errors, even when there is no perceived harm to the patient. Additionally the administrators should do a root cause analysis of the incidents to identify barriers to report ing errors. With enough information on the reasons for late medications, hospita ls can change processes and eliminate some of these causes. As barriers are removed and medications are more easily delivered on time, the values conflict or moral distress that may be perceived by the registered nurses should decrease. In turn, perhaps this might decrease the numbers of RNs leaving the acute care setting. The relationship between ethical ideo logy and professional values on a registered nurses intention to act accountably lends support for schools of nursing to require course work in ethics and the ANA Code of Ethics. This course work should include clinical situations faced by registered nurses where the nurse must make decisions to act acc ountably. One suggestion is to include

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82 vignettes where the medicine is administer ed within the allowable time (one hour before or up to one hour after a scheduled administration time); will the nurses report the exact time of administration or will they report the scheduled time of administration? Education might focus on the unintended consequences of not acting accountably even in the seemi ngly harmless scenario of giving a medication within the two hour window allowed, but not at the exact time ordered. Documenting actual adminis tration time versus scheduled administration time remains critical to the safety of the pati ent even if no error occurred. Knowing that the expectations of the practice environm ent may conflict with the professional values learned during nursing education, schools of nursing may wish to focus on enhancing the students strategies fo r coping with potential conflicts. Recommendations for Future Research The results of this study suggest seve ral areas for future research in practice and education. Future studies regarding the completion of incident reports might explore the following areas : (a) barriers to completing incident reports, (b) physicians beliefs and pref erences regarding receiving error notification, (c) barriers to notifying t he physician, and (d) barriers to recording the accurate time of admini stration. First, this study corroborated prior research that medication errors are under report ed. A future study could measure the impact of targeted training for inci dent reporting and of implementing a nonpunitive error-reporting system. Second, although it is assumed the ph ysician would want to know if a medication is late regardless of any apparen t effect on the patient, this has not

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83 been shown in the literature. Therefore, another line of inquiry would be to assess physicians preferences for being notified, by what mechanisms and in what time frames. Third, while it is hospital policy to notify the physician if an injury with apparent harm occurs, some registered nur ses indicated that they would not notify the physician. The reasons for nur ses failing to comply with mandated policies deserve further exploration. A future study could use a qualitative approach framing questions around the acquisition of knowledge and Benners (1982) novice to expert conceptual framework. Fourth, future studies could explore what actions the registered nurses take when medications are late. For example, do they re-tim e the medication or instead do they keep administration ti mes the same? Another study might examine the perceptions t hat registered nurses have regarding what constitutes a non-punitive error reporting environment and what effect t he documentation of names on error report forms has on their careers. Fifth, a replication of this study using a wider population with more covariates is indicated. The aim would be to further identify predictors of nurses actions when faced with clinical vignette s where medication administration errors occur. Since registered nurses are faced wit h value conflicts daily, further research could explore the effect of these tensions on retention and job satisfaction. In addition, the paperwork ent ailed in error repor ting might create a

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84 fear of liability that causes some nurse s to leave nursing, thus exacerbating the nursing shortage. Development of professional values offers another area for future research. It is not known if professional va lues continue to develop or strengthen post graduation. Additionally the role of the ANA Code of Ethics in the decision process of registered nur ses on a daily basis is not known. The relationship between ethical ideo logy and professional values may cause schools of nursing to consider administering the Ethical Position Questionnaire as part of a battery of pr e-admission tests. Current evidence does not support administration of this inst rument as an effective pre-admission screening tool. A longitudinal study may be developed to explore this area. An additional arm to that study would be to use experience-bas ed questions during an admission interview to determine the effectiveness of that technique in admitting individuals who score high on a measure of professional values. Limitations The study sample was a convenience sample drawn from a four-hospital system on the south west coast of Florida. Therefore, it may not be generalizable to a region, state or nation. The investi gator is employed in a non-managerial role in this system. The sample size of 215 was smaller than the 256 that the power analysis indicated was needed. Data collection was discontinued before reaching 256 respondents because all avenues for distribution of the survey had been explored and no additional surveys had been returned in more than one week.

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85 The post hoc power analysis indicated this study was under powered to detect significant effects of relativism on profe ssional values (Hypothesis 1). In contrast, there was more power to det ect the effects of idealis m than relativism. This finding may account for the signific ant main effect of idealism. The accountability instrument was author developed and had an acceptable Cronbachs alpha coefficient (.74) according to Polit (1991). Correlations between the corresponding i ndividual questions in the two vignettes were high for the first two questions regarding documentation of time of medication administration and notification of the physician. The third question pertaining to completion of an in cident report had a low but acceptable correlation. This would need to be re-test ed in different situations to further develop the accountability measure. Conclusion Ethical idealism but not relativism was found to have a significant effect on a measure of nurses prof essional values. Although absolutists (adherents to strict moral principles) scored highest on all measures of accountability, there was only one instance where ethical ideo logy did have a significant effect on accountability. This effect emerged w hen Question 3 (completion of an incident report) was analyzed separately from the other questions, while controlling for age. The study was drawn from a fourhospital health care system on the west coast of Florida therefore the results are not generalizable. Replication of the study drawing from a larger population is recommended.

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86 Summary This study is the first to attempt to link ethical ideology and professional values with a nurses intention to act a ccountably. Ethical ideology was linked to a measure of professional values; however it was not linked to a measure of accountability. Although not generalizable, t he results of this study suggest the need for further research to ascertain the role of professional values on a registered nurses intention to act acc ountably. This further exploration is important to move the body of knowledge forward in the area of accountability in nursing.

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97 Levine, M. (1977). Nursing ethics and the ethical nurse. American Journal of Nursing 77 (5), 845-849. Levitt, E., Lubin, B., & Zuckerman, M. (1962). The student nurse, the college woman and the graduate nurse : A comparative study. Nursing Research 11 (2), 80-82. MacAndrew, C. & Elliott, J. (1959). Varyi ng images of the professional nurse: A case study. Nursing Research 8 (1), 33-35. Martin, P., Yarbrough, S., & Alfred, D. (2003). Professional values held by baccalaureate and associate degree nursing students. Journal of Nursing Scholarship, 35 (3), 291-296. Martin, P. (2005, July). The influence of a nursing educ ational experience on the development of professional values : Round one, entry level values. Paper presented at the 16th International Nursing Research Conference Renew Nursing through Scholarship. Retr ieved September 6, 2008, from http://stti.confex.com/stti/i nrc16/techprogram/paper23814.htm May, W. & Ilardi, R. (1970) Change and stability of values in colle giate nursing students. Nursing Research, 19(4), 359-362. Maze, C. D. (2005). Registered nurses personal rights versus professional responsibility in caring for members of underserved and disenfranc hised populations. Journal of Clinical Nursing 14(5), 546-554. McAlpine, H., Kristjanson, L., & Poroch D. (1997). Developm ent and testing of the Ethical Reasoning Tool (ERT) : An instrument to me asure the ethical reasoning of nurses. Journal of Advanced Nursing 25 (6), 1151-1161.

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98 McNeese-Smith, D. & Cr ook, M. (2003). Nursing values and a changing nurse workforce. Journal of Nursing Administration 33(5), 260-270. Memarian, R., Salsali, M., Zohreh, V., Ahmadi, F., & Halzadeh, E. (2007). Professional ethics as an important factor in clin ical competency in nursing. Nursing Ethics 14(2), 203-214. Miles, C. (1934). The personalit y development of student nurses. Am erican Journal of Nursing 34 (2), 175-184. Miller, D. (1965). Characteristics of graduate students in four clinical nursing specia lties. Nursing Research 14(2), 106-113. Moore, S., & Hutchison, S. (2007). Developing l eads at every level: Accountability and empowerment ac tualized through shared governance Journal of Nursing Administration, 37 (12), 564-568. Morreim, E.H. (2004). Medical errors: Pi nning the blame versus blaming the system. In V. Sharpe, D. Calla han, & Kaebnick, G. (Eds.), Accountability: Patient safety and policy reform (pp. 213-232), Washington, DC: Georgetown University Press. Moscinski, D. (2008). Professionalism for all. Education Digest, 73 (8), 40-42 Myers, J., Frieden, T., Bherwanit, K., & Henning, K. (2008). Research: Privacy and public health at risk: Public health confidentiality in a digital age. Ethics in Public Healt h, 98 (5), 793-801. National League of Nursing A ccrediting Com mission (2008). Standards and Criteria (Baccalaureate). Retrieved August 10, 2008, from http://www.nlnac.org/manuals/SC2008BACCALAUREATE.pdf

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99 Navran, L. & Stauffacher, J. (1957). T he personality structure of p sychiatric nurses. Nursing Research, 5 (3), 109-114. OLeary, D. (2003) Patient safety: Instillin g hospit als with a culture of patient safety. Testimony before the Senate Commi ttee on Governmental Affairs on Capitol Hill on June 11, 2003. Retrieved June 8, 2008 from http://www.jointcommission.org/News Ro om/OnCapitolHill/testimony0611 04.htm ONeill, M. (1973). A study of baccalaureate nursing student values Nursing Research, 22(5), 437-443. ONeill, M. (1975) A study of nursing student values. International Journal of Nursing St udies, 12, 175-181. OSullivan, A.J. & Toney, S. M. (2008). Assessment of professionalism in undergraduate medical students. Medical Teacher 30(3), 280-286. Pendry, P. (2007). Moral distress: Recogniz ing it to retain nurses. Nursing Economics, 25(4), 217-221. Perry, G. (1907). Nursing ethics and etiquette. American Journal of Nursing 7 448. Peshek, S. & Cubera, K. (2004). Non punitiv e voicemail-based medication error reporting system. Hospital Pharmacy, 39 (9) 857-863. Polit D. & Hungler, B. (1999). Nursing research principles and m ethods (6th ed.). Philadelphia, Lippincott.

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100 Potylycki, M., Kimmel, S., Ritter, M., Capua no, T., Gross, L., Riegel-Gross, K., et al. (2006). Nonpunitive medication e rror reporting: 3-year findings from one hospital's primum non nocere initiative. Journal of Nursing Administration 36(7), 370-6. Prosen, B. (2007). How leaders in crease accountability and results. Supervision 68(3), 13-15. Rassin, M., Kanti, T., & S ilner, D. (2005). Chronology of medication errors by nurses: Accumulation of st resses and PTSD symptoms. Issues in Mental Health Nursing 26, 873-886. Rassin, M. (2008). Nurses professional and personal values. Nursing Ethics 15(5), 614-630. Redden, J. & Scales, E. (1961). Nursing education and personality characteristics. Nursing Research 10(4), 215-218. Redman, B. (1966). Predomi nant values of select ed intermediate nursing students and of their c linical teachers. Nursing Research, 15(4), 348-350. Rokeach, M. (1973). The nature of human values New York: The Free Press. Rothert, ML (1982). Physicians and pati ents judgment of compliance with a hypertensive regimen. Medical Decision Making 2 (2), 179-195 Rowe, J.A. (2000). Accountabi lity: A fundamental component of nursing practice. British Journal of Nursing 9, 549-552. Schank, M.J. & Weis, D. (1989). A study of baccalaureate nursing students and graduate nurses from a secula r and a non-secular program. Journal of Professional Nursing 5 (1), 17-22.

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102 Stein, R. (1969). The student nurse: A study of needs, roles, and conflicts, part II. Nursing Research, 18(5), 433-440. Steiney, J. (2008). Holding higher educ ation accountable for new teachers. School Administration, 65(3), 46. Stump, L. (2000) Re-engi neering the medication e rror reporting process. Removing the blame and im proving the process. American Journal of Health System Pharmacy 57(24), supp. 37. Sullivan, J. (1978). Comparison of mani fest needs of nurses and physicians in primary care practice. Nursing Research 27(4), 255-259. Tansey, R., Brown, G., Hyman, M., & Dawson, L. (1994). Personal moral philosophies and the moral judgments of sales people. Journal of Personal Selling & Sales Management 14(1), 59-76. Texas Education Agency. (2008). Accountability rating system for Texas public schools and districts Retrieved May 30, 2008 from http://www.tea.state. tx.us/perfreport/account Thurston, H., Flood, M., Shupe, I., & Gera ld, K. (1989). Values held by nursing faculty and students in a university setting. Journal of Professional Nursing, 5 (4), 199-207. Thurston, J., Brunclik, H., & Feldhusen, J. (1969). Personality and the prediction of success in nursing. Nursing Research 18(3), 258-262. Tilley, S. (2008). Competency in nursing: A concept analysis. Journal of Continuing Education in Nursing 39(2), 58-64.

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103 Twomey, J. (1989). Analysis of the claim to distinct nursing ethics: Normative and non-normative approaches. Advances in Nursing Science 11 (3), 25-32. U, D. (2001). Medication error repor ting systems: Problems and solutions. New Medicine 1 (2), 61-65. United Nations. (2007). Universal declaration of human rights. Retrieved June 22, 2007, from http://www.un.org/Overview/rights Varcoe, C., Doane, G., Pauly, B., Rodney P., Storch, J., Mahoney, K., et al. (2004). Ethical practice in nursing: Nursing the in-betweens. Journal of Advanced Nursing, 45 (3), 316-325. Veatch R. M. (1989) Medical ethics: An introduction Boston, MA, US: Jones and Bartlett Publishers. Vincent, P, Brewer, M.J., Aslakson, H., & Swanson, M. (1993) Are we teaching leadership as a value? Nursing Management 24(7), 65-69. Walsh, M. (1996). Accountability and intu ition: Justifying nursing practice. Nursing Standard 11(23), 39-41 Waterman, A. (1988). On the uses of p sychological theory and research in the process of ethi cal inquiry. Psychological Bulletin, 103 (3), 283-298. Watson. P, Murry, R., Millir on, J., & Stutz, N. (1998) Religious orientation, identity and the quest for meaning in ethics within an ideological surrounding. International Journal of Psychology of Religion, 8 (3), 149-64. Weis, D. & Schank, M. J. (2000). An inst rument to measure professional nursing values Journal of Nursing Scholarship 32(2), 201-204.

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104 West, J. (2007). Ethical issues and new nur ses: Preventing ethical distress in the work environment. Kansas Nurse 82(4), 5-8. White, M. (1975). Psychological charac teristics of the nurse practitioner. Nursing Outlook 23(2), 160-166. Williams, M., Bloch, D., & Blair, E. (1978). Values and value changes of graduate nursing students: Their relationship to faculty values and to selected educational factors. Nursing Research, 27(3), 181-190. Yarling, R. & McElmurry, B. (1986). The moral foundation of nursing. Advances in Nursing Science, 8 (2), 63-73.

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105 Appendix A: Information About Subjects

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106 SURVEY BOOKLET FACE SHEET Registered Nurses Thank you for your interest in this study. Your participation is strictly voluntary. There is no individual benefit or risk to you for participating. All information is confidential. Your responses are anonymo us. No individual data will be reported to your employer. Your consent to parti cipate in this study is assumed if you return the completed survey booklet to the investigator. It will take you approximately 15 minutes to complete the survey. Before putting your completed survey in the interoffice envelope provided, look to make certain you answered all questions. Put the survey in the self addressed interoffice envelope and return to: Sue Hartranft MS 430 by June 15, 2007 Thank you. Sue Hartranft 734-6140

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107 Information Questionnaire Instructions: Provide answers to the following questions by circling or checking the most appropriate response. Age: __________ Gender: Male Female Race/Ethnicity: Caucasian African Am erican Asian Pacific/Islander Hispanic Native American Caucasian What is your highest level of education? Circle one below Diploma Associate Degree Bachelors Degree Masters Degree PhD What is your current position? Circle one below CNR CNI CNII CNIII Agency/Traveler Other How long have you held th is position? ______________________ How many years have you been a Registered Nurse? _______________ What shift do you work? ____________ _______________ What certifications do you hold? ______ ___________________ Did you study the ANA Code of Ethics in you nursing program? Yes No Did you take an ethics class in your nursing progr am? Yes No How religious do you consider yourself to be? Not Religious Somewhat Religious Very Religious Extremely Religious 1 2 3 4 5 6 7 8 9 10

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108 Appendix B : Ethical Position Questionnaire

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109 Appendix B Ethical Position Questionnaire Instructions: Please read each statement carefully. Then indicate the extent to which you agree or disagree by placing in front of the statement the number corresponding to your feelings, where: 1 = Completely disagree 4 = Slight ly disagree 7 = Moderately agree 2 = Largely disagree 5 = Neither agree nor disagree 8 = Largely agree 3 = Moderately disagree 6 = Slightly agree 9 = Completely agree ____ 1. A person should make certain that their actions never intentionally harm another even to a small degree. ____ 2. Risks to another should never be tolerat ed, irrespective of how small the risks might be. ____ 3. The existence of potential harm to othe rs is always wrong, irrespective of the benefits to be gained. ____ 4. One should never psychologically or physically harm another person. ____ 5. One should not perform an action, whic h might in any way threaten the dignity and welfare of another individual. ____ 6. If an action could harm an innocent other, then it should not be done. ____ 7. Deciding whether or not to perform an act by balancing the positive consequences of the act against the negative consequences of the act is immoral. ____ 8. The dignity and welfare of people shoul d be the most important concern in any society. ____ 9. It is never necessary to sa crifice the welfare of others. ____ 10 Moral actions are those, which closely ma tch ideals of the most perfect action. ____ 11 There are no ethical principles that are so important that they should be a part of any code of ethics. ___ 12 What is ethical varies from one situation and society to another. ____ 13 Moral standards should be seen as being individualistic; what one person considers to be moral may be judged to be immoral by another person. ____ 14 Different types of moralities cannot be compared as to rightness. ____ 15 Questions of what is ethical for everyone can never be resolved since what is moral or immoral is up to the individual. ____ 16 Moral standards are simply personal rules which indicate how a person should behave, and are not to be applied in making judgments of others. ____ 17 Ethical considerations in interpersonal relations are so complete that individuals should be allowed to formulate their own individual codes. ____ 18 Rigidly codifying an ethical position that prevents certain types of actions could stand in the way of better human relations and adjustment. ____ 19 No rule concerning lying can be formul ated; whether a lie is permissible or not permissible totally depends upon the situation. ____ 20 Whether a lie is judged to be moral or immoral depends upon the circumstances surrounding the action.

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110 Appendix C : Nurses Professi onal Values Scale Revised

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111 Nurses Professional Values Scale-R Indicate the importance of the following value statements relative to nursing practice. Please circle the degree of importance. (A = not important to E = most important) for each statement. Not Important Somewhat Important Important Very Important Most Important A B C D E 1. Engage in on-going self-evaluation. A B C D E 2. Request consultation/collaboration when A B C D E unable to meet patient needs. 3. Protect health and safety of the public. A B C D E 4. Participate in public policy decisions A B C D E affecting distribut ion of resources. 5. Participate in peer review. A B C D E 6. Establish standards as a guide for practice. A B C D E 7. Promote and maintain standards where planned A B C D E learning activities for students take place. 8. Initiate actions to improve environments A B C D E of practice. 9. Seek additional education to update knowledge A B C D E and skills. 10. Advance the profession through active A B C D E involvement in health related activities. 11. Recognize role of professional nursing A B C D E associations in shaping health care policy. 12. Promote equitable access to nursing and A B C D E health care. 13. Assume responsibility for meeting health A B C D E needs of the culturally diverse population. 14. Accept responsibility and accountability for A B C D E own practice. 15. Maintain competency in area of practice. A B C D E 16. Protect moral and legal rights of patients. A B C D E 17. Refuse to participate in care if in A B C D E ethical opposition to own professional values. OVER

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112 Nurses Professional Value Scale r Page 2 Not Important Somewhat Important Important Very Important Most Important A B C D E 18. Act as a patient advocate. A B C D E 19. Participate in nursing research and/or A B C D E implement research findings appropriate to practice. 20. Provide care without prejudice to patients A B C D E of varying lifestyles. 21. Safeguard patient's right to privacy. A B C D E 22. Confront practitioners with questionable A B C D E or inappropriate practice. 23. Protect rights of participants in research. A B C D E 24. Practice guided by principles of fidelity A B C D E and respect for person. 25. Maintain confidentiality of patient. A B C D E 26. Participate in activities of professional A B C D E nursing associations. Please feel free to make comments : Copyright 2004, Darlene Weis & Mary Jane Schank DW/MJS

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113 Appendix D: Account ability Instrument

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Accountability Instrument Vignette A Instructions: Carefully read each of the statements below. Indicate the extent to which you would respond in the situation by placing in front of the statement the number corresponding to your likely action when Not Likely Slightly Likely to do Might do Very Likely to do Extremely Likely to do 1 2 3 4 5 6 7 8 9 10 Situation You are caring for a 54 year old patient who is scheduled for an IV antibiotic every 4 hours. You will need to administe r at 1000 and 1400. You forget and do not administer the 1000 dose until 1200. ______How likely would you be to document the administration time as 1200? ______How likely would you be to co mplete an incident report? ______How likely would you be to call the physician? How realistic is this hypothetical clinical situation? Very Unrealistic Realistic Very Realistic Extremely Realistic 1 2 3 4 5 6 7 8 9 10

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115 Accountability Instrument Vignette B Instructions: Carefully read each of the statements below. Indicate the extent to which you would respond in the situation by placing in front of the statement the number corresponding to your likely action. Not Likely Slightly Likely to do Might do Very Likely to do Extremely Likely to do 1 2 3 4 5 6 7 8 9 10 Situation You are caring for a 54 year old patient who is scheduled for an IV antibiotic administration every four hour s. You will need to administer the antibiotic at 1000 and 1400. You forget and do not administe r the 1000 dose until 1200. At that time you realize the patient has an elevated temp of 101.8. ________How likely would you be to document the administration time as 1200? ________How likely would you be to complete an incident report? ________How likely would you be to call the physician? How realistic is this hypothetical clinical situation? Very Unrealistic Realistic Very Realistic Extremely Realistic 1 2 3 4 5 6 7 8 9 10

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About the Author Susan Hartranft received a Bachelors Degree in Nursing from Albright College in 1977 and a M.S. in Nursing from the University of South Florida in 1984. Currently employed by Morton Plant Mease Health Care in Clearwater, Florida she has responsibility for the Nu rsing Research Center. Additionally Ms. Hartranft serves on the Clinical Adviso ry Board for the University Of South Florida College Of Nursing and was instrumental in assisting the College to develop the Clinical Nurse Leader Program. She remains as courtesy faculty for the College of Nursing. While in the Ph.D. program Ms Hartranft served as the student representative on the Ph.D. Curriculum Committee. An active member of the Florida Nurses Association she currently serves on the Board of Directors and is Chair of the Workforce Advocacy Commissi on. Additionally she is an inaugural member of the American Association of Colleges of Nursing Commission on Nurse Certification Board of Directors.


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The effect of ethical ideology and professional values on registered nurses' intentions to act accountably
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ABSTRACT: Hospitals today focus on creating a culture of patient safety and reducing error. Registered nurses are mandated by the American Nurses Association's Code of Ethics to advocate for the patient at all times and to act accountably to ensure patient safety. There is a paucity of literature relating to how nurses' values and ethical ideology may affect their decision to act accountably. This study tested two hypotheses. Hypothesis 1 predicted that registered nurses who demonstrated a low relativistic ethical ideology would score higher on a measure of professional values than would registered nurses who demonstrate a high relativistic ethical ideology. Hypothesis 2 predicted an order of ethical ideology (absolutists then exceptionists, subjectivists and situationists) in scores on a measure of accountability. A descriptive non experimental design was used.Registered nurses (n=215) employed on the west coast of Florida completed a demographic form, Ethical Position Questionnaire (EPQ), Nurses Professional Values Scale Revised (NPVSR) and an investigator developed accountability instrument. A median split on the scores of the relativism and idealism scales on the EPQ formed the four groups of ethical ideology; absolutists, exceptionists, subjectivists and situationists. The accountability instrument consisted of 2 hypothetical clinical vignettes involving a late antibiotic administration. Using a Likert type scale, the participants answered three questions regarding how likely they would be to record the actual time of medication administration, call the physician and complete an incident report. Hypothesis I was not supported. Idealism (p=.001) not relativism had a significant effect on professional values. Hypothesis II was not supported.Absolutists scored highest on measures of accountability followed by exceptionists, situationists and subjectivists. When controlling for age, idealism not relativism had a significant effect on completing an incident report (p = .03). This is the first study to examine the effect of ethical ideology on professional values and a registered nurse's intention to act accountably. Previous studies described values held but did not link the descriptions to intentions to act. The information may be useful to hospitals as they build a culture of patient safety and develop a workforce that is accountable for its actions and decisions.
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Moral development
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Patient safety
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Attitude of Health Personnel.
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