RESEARCH
ABSTRACT As the scope of advanced practice nursing expands and the
educational requirements increase, so do the ethical responsibilities.
How prepared are advanced practice nurses (APNs) to manage the ethical
challenges in advanced practice? The purpose of this study was to
determine APNs' ethics knowledge and perceived level of confidence
in their ability to manage ethical problems in advanced practice.
Assuming ethics knowledge and abilities of APNs are similar to those of
medical residents, a survey instrument for medical residents was
modified for use with APNs. Responses to the modified survey indicated a
fairly high level of confidence but a fairly low level of knowledge.
Studies show that ethics education can be effective in improving
knowledge, confidence, and ethical behavior. Given the expanding role of
APNs as doctors of nursing practice, research is needed to determine the
ethics knowledge needs and teaching strategies to better prepare nurses
for the challenges of advanced practice.
Key Words Ethics Education--Advanced Practice Nursing--Ethical
Decision-Making--Ethics Confidence--Ethics Knowledge
**********
COMPARED TO NURSING STUDENTS IN BACCALAUREATE PROGRAMS, THE ETHICS
EDUCATION OF ADVANCED PRACTICE NURSES (APNS) HAS RECEIVED LITTLE
ATTENTION. As the scope of APN practice expands and educational
requirements increase to the level of doctor of nursing practice (DNP),
so do the ethical responsibilities of APNs. As curricula are developed
to prepare nurses for the DNP degree, it is important to know which
areas of ethics education need to be addressed to help APNs in the
management of ethical challenges.
Ketefian (1999) reported extreme variation in the outcome
competencies of nursing students at the graduate level regarding ethics
content. This is unfortunate. Studies have shown that some APNs
experience moral distress when managing ethical problems in clinical
practice that lead to negative consequences for them and for their
patients (Butz, Redman, Fry, & Kolodner, 1998; Godfrey & Smith,
2002; Laabs, 2005, 2007). It has been suggested that ethics education
may increase nurses' confidence (Grady et al., 2008; Wocial, 2008)
and serve as an antidote to the professional ill of moral distress
(Lang, 2008, p. 19).
Given the problem of moral distress and its contribution to the
ongoing nursing shortage, along with the increasing demands of a complex
health care environment and the trend toward APN educational preparation
at the DNP level, attention needs to be given to ethics education of
advanced practice nurses. This article reports on a cross-sectional
descriptive survey of APNs regarding their knowledge of ethics and their
perceived level of confidence in their ability to manage ethical
problems in clinical practice. It is hoped that findings from this study
will help lay the groundwork for ensuring that appropriate ethics
content is included in the essential elements of curricula, both for
experienced APNs who return for doctoral degrees and for individuals
entering DNP programs directly from baccalaureate programs. It is hoped
also that these findings will begin to remedy the problem of moral
distress that continues to afflict nursing at all levels.
Review of the Literature and Conceptual Framework
No studies on ethics knowledge and confidence were found concerning
APNs. However, studies have been conducted among interns entering
medical residency, a group that would have similar ethics knowledge
requirements. These studies found that, despite ethics education in
medical school, ethics knowledge and confidence among medical interns
were generally low; and, while confidence was high among surgical
interns, their requisite ethics knowledge was low (Sulmasy, Ferris,
& Ury, 2005). Studies among practicing physicians and physicians in
residency programs have demonstrated that ethics education following
medical school can be effective in improving knowledge, confidence, and
behavior in ethical decision-making (Sulmasy & Marx, 1997; Sulmasy,
Dwyer, & Marx, 1995; Sulmasy, Geller, Levine, & Faden, 1990,
1993; Sulmasy, Terry, Faden, & Levine, 1994).
Although ethics knowledge was not measured and findings specific to
APNs were not known, Grady and colleagues (2008) found that ethics
education had a positive influence on nurses' moral confidence,
moral actions, and use of ethics resources. Assuming that APNs, like
medical residents, would benefit from postgraduate ethics education, it
is important to know what exactly such education should entail. In a
survey of MSN programs in the United States, Burkemper, DuBois, Lavin,
Meyer, and McSweeney (2007) found that there were no guidelines or
standards relevant to ethics content in MSN curricula. Further, there
were gaps in the clinical ethics topics addressed and few common trends
among programs. Ethics education in medical schools was more rigorous
and demanding of students than that of nursing schools, yet medical
schools saw their programs as having serious weaknesses in need of
attention (DuBois & Burkemper, 2002).
This author formulated a Grounded Theory of Maintaining Moral
Integrity in the Face of Moral Conflict (Laabs, 2007). According to this
theory, ethics knowledge and self-confidence are among the factors that
influence primary care nurse practitioners in the process of managing
ethical problems and maintaining moral integrity. The value of measuring
perceived confidence is supported by Social Learning Theory, which
advises that perceived self-efficacy (confidence), while important, is
not the sole determinant of behavior if requisite competencies are
lacking (Bandura, Adams, & Beyer, 1977). Ethics knowledge is one
such competency. Thus, both ethics knowledge and perceived confidence
are worth measuring.
Method DESIGN AND SAMPLE The sample consisted of all graduates of
one midwestern university college of nursing graduate studies program
who obtained an MSN degree or postmaster's certificate between the
years 1992 (when the program began) and 2007 (N = 363). Practice options
for the MSN degree or certificate included nurse-midwifery, pediatrics,
adults, older adults, and acute care adult. The university's
institutional review board approved the study; the alumni association
provided the names and addresses of potential participants.
THE SURVEY INSTRUMENT The survey was an anonymous, self-report
questionnaire that consisted of: a) demographic information, b) a
perceived confidence level scale, and c) an ethics knowledge test. The
perceived confidence scale and the ethics knowledge test were developed
by Sulmasy and colleagues (1990) for use among medical residents. The
original scale demonstrated internal reliability consistency of greater
than 0.80 in several studies by Sulmasy and colleagues (1990, 1993,
1995, 1997, 2005).
The original instrument was adapted by the investigator, in
consultation with four experts, for the purpose of this study. All
experts were prepared at the doctoral level and had experience and
expertise teaching health care ethics to nurses and physicians (one was
a physician/ethicist/researcher, two were nurse ethicists/ researchers,
and one was a philosopher/ethicist). Content validity for the adapted
instrument was established by the panel of experts, which included a
developer of the original instrument.
The content of the adapted instrument was based upon current ethics
literature in nursing as described by the American Association of
Colleges of Nursing [AACN] Essentials for Baccalaureate Education
(1998), Master's Education (1996), and Doctoral Education (2006),
and in literature by nursing ethics scholars (Ketefian, 1999; Milton,
2004). Each expert reviewed each item and rated it on a four-point
scale, with scores ranging from zero (not at all) to 3 (completely) as
to relevance, representativeness, specificity, and clarity relative to
the content area. Items were revised until ratings in each area were
unanimous among the experts and rated at a minimum of two points.
Reproductive care had not been included in the original instrument but
was added to the adapted scale, as APNs may provide this service. Items
based on the American Nurses Association (ANA) Code of Ethics (2001)
were added to the ethics knowledge portion of the instrument.
As was true of the original scale, the adapted perceived confidence
scale was based on Social Learning Theory and the concept of
self-efficacy as described by Bandura and colleagues (1977). The adapted
scale remained in its original five-point Likert format, with scores
ranging from 1 (very low confidence) to 5 (very high confidence). The
abilities that were measured are found in Table 1.
The final adapted survey began with 14 demographic items plus one
item for participants to rate how well their ethics education had
prepared them to manage ethical issues that they encounter in advanced
practice; scores ranged from 1 (not at all) to 5 (excellent). This was
followed by the perceived confidence scale containing nine items; it
concluded with 27 items in a multiple-choice format intended to measure
ethics knowledge.
DATA COLLECTION AND ANALYSIS A packet of four items was mailed to
each prospective participant. The packet contained a cover letter
explaining the research study and inviting participation, a copy of the
survey, a stamped envelope addressed to the investigator, and a
five-dollar gift card to a nationally recognized coffee shop in
appreciation for participation. The packet was mailed to the permanent
address on record of all eligible participants. Consent was implied by
return of a completed survey. Data were collected over a six-month
period in 2007 and were analyzed using SPSS 15.0 statistical software
for frequency distributions. Categorical variables were analyzed using
cross tabulations and the Chi-Square test. Cronbach's alpha for the
confidence scale was found to be 0.86 for this sample.
Results SAMPLE CHARACTERISTICS Of the 363 surveys mailed, 172 were
returned completed for a 47 percent response rate. Respondents practiced
in 18 states; all but six were women. Ages ranged from 25 to 65 (M = 42,
SD = 9.2). Only three respondents (1.7 percent) held doctoral degrees.
Nearly all had taken an ethics course during their APN education (162,
94 percent); most indicated that their ethics education had been fair
(51, 29.7 percent) or good (91, 52.9 percent). (See Table 2.)
CONFIDENCE As shown in Table 1, on a five-point Likert scale, APNs
indicated having the greatest confidence in their ability to recognize a
genuine ethical problem in clinical practice (M = 4.26, SD = 0.69) and
the lowest confidence in their ability to understand and manage ethical
aspects of reproductive health (M = 3.25, SD = 1.23). Overall, their
confidence in their ability to manage ethical problems was fairly high
(M = 3.70, SD = 0.93).
KNOWLEDGE Ethics knowledge scores varied widely. Of the 172
participants, the mean number that scored correctly on any single item
was 94.69 (SD = 45.47); in other words, the average score on the test
was 55.05 percent correct (SD = 26.43). Participants scored highest in
their understanding of the principle of accountability in the ANA Code
of Ethics (93.6 percent answered correctly), followed by knowledge of
the Patient Self-Determination Act and Advance Directives (91.9 percent
answered correctly). They scored lowest in knowledge of the definition
of classic utilitarianism (6.4 percent answered correctly). Knowledge
area items, the corresponding number of participants who answered the
item correctly, and the percent of correct responses are depicted in
Table 3. No associations were found between confidence and knowledge or
between confidence or knowledge and age, gender, specialty, or years in
practice.
Discussion Overall, respondents to this study indicated a fairly
high level of confidence in their ability to manage ethical problems in
clinical practice; however, their overall ethics knowledge was low.
Compared to studies of medical residents using similar instruments, the
APNs in this sample had slightly higher levels of confidence and
knowledge but greater variation in ethics knowledge scores (Sulmasy et
al., 2005). Higher confidence scores may be due to the greater amount of
clinical experience that APNs tend to have compared to medical
residents. According to Bandura et al. (1977), perceived mastery
experiences are strong predictors of personal self-efficacy. However,
APN confidence scores were only slightly higher than those of medical
residents, which may suggest that negative experiences (personal or
vicarious), may decrease personal self-efficacy as supported by Social
Learning Theory.
The author's Grounded Theory of Maintaining Moral Integrity in
the Face of Moral Conflict identifies role expectations as an
influencing factor in the process of managing ethical problems (Laabs,
2007). The degree to which the APN participants felt it was their role
to make decisions when ethical problems occur may have influenced the
degree of self-efficacy. Social Learning Theory states that social
persuasion or social support can increase self-efficacy whereas negative
social support can decrease it (Bandura et al., 1977). If APNs do not
see ethical decision-making as part of their role or do not feel
supported in their decision-making, they may fail to participate in the
decision-making process. However, when APNs implement the decisions of
others (e.g., physicians, patients, and administrators), they are, in
fact, involved in the process. If APNs disagree with a decision but feel
unable to articulate and justify their position and feel powerless to do
anything other than what they are instructed to do, this could lead to a
situation of moral distress.
Although the majority of respondents indicated that they had an
ethics course during their APN education and felt that their preparation
was fair or good, survey results did not reflect such knowledge. The
wide variation of knowledge scores may suggest more guesswork than
knowledge. This could reflect the variation in ethics education within
graduate nursing programs, or, since all the participants graduated from
the same university, it may suggest variations within programs of study
over the course of time.
Variation in knowledge scores may have been influenced by the
amount of time since the participant's last ethics instruction,
number of years in practice, or area of practice. If an APN, for
example, never worked in pediatrics, lack of familiarity with Baby Doe
laws would not be a surprise. While it does not seem unreasonable to
assume that some ethics knowledge should be common to all APNs, perhaps
specific items targeted to APNs in particular areas of practice would be
a better measure of individual knowledge.
Knowledge scores may also have been influenced by variation in
value perspective, that is, one's point of view about what is of
value and the framework that one uses to justify one's actions when
faced with moral conflict (Laabs, 2007). Value perspective has been
found to vary among APNs and influence the ability to recognize ethical
dimensions of patient situations (Laabs). Thus, interpretation of items
on the knowledge portion of the survey may have contributed to the wide
variation in scores.
The method and length of ethics education and the knowledge of the
ethics instructor may make a difference in APN knowledge and confidence.
This was found to be the case among medical residents. For example,
after a two-year period of ethics education during medical education,
ethics knowledge of residents significantly improved in all areas
tested, including knowledge of ethical theories and principles, landmark
ethical cases, and knowledge of pertinent laws (Sulmasy & Marks,
1997). Sulmasy et al. (1993) also found that a lecture series was not as
effective at increasing knowledge, confidence, and ethical behavior
among medical residents as was a lecture series combined with case
conferences with an ethicist in attendance. Sulmasy et al. (1995) found
that, while confidence in ethical decision-making was significantly
higher among medical faculty, ethics knowledge scores were just as low
as those of the residents they were teaching. Thus, besides content, how
ethics is taught and who teaches it is important.
Limitations The study is limited by the homogeneity and small size
of the sample. Levels of knowledge and confidence may differ among those
who, unlike the sample, have not had formal education in ethics, are
from a more diverse population, or are graduates of a variety of
educational institutions. Year of graduation from the APN program was
not requested, nor was the date of the APN's last ethics education
experience. Analysis of such data and possible associations with
knowledge and confidence may be helpful for planning graduate and
continuing education programs.
Even though content validity for the modified survey was
established by a four-person panel of experts, there is a lack of expert
consensus on ethics content knowledge for APNs as reported by Burkemper
et al. (2007). Thus, other experts may rule differently on the content
and survey questions. Furthermore, there is no consensus on the value of
an objective exam for measuring nurses' knowledge of ethics. Still,
without some means of measuring knowledge, it is difficult to evaluate
the effectiveness of ethics education and provide evidence of its value
to nurses and the patients for whom they provide care.
Conclusions and Recommendations APNs in this sample showed a fairly
high level of confidence in their ability to manage ethical problems,
but their overall ethics knowledge was low. Compared to studies of
medical residents using similar instruments, this sample had slightly
higher levels of confidence and knowledge but greater variation in
ethics knowledge scores (Sulmasy et al., 2005). Higher confidence scores
may be due to the greater amount of clinical experience that APNs tend
to have compared to medical residents, but may be only slightly higher
due to negative vicarious experiences, which may decrease personal
self-efficacy.
Wide variations in ethics knowledge scores may have been influenced
by variations in work environment, ethics education, experiences in
clinical practice, role expectations, and value perspectives, which have
been found to be factors that influence the process of managing ethical
problems in nurse practitioner practice (Laabs, 2007). Because of the
wide variability in knowledge scores in this sample and the small sample
size, the validity and reliability of the knowledge instrument, in its
current form, may not be optimal. The instrument needs further analysis,
development, and testing.
Research shows that ethics education can be effective in improving
knowledge, confidence, and behavior among RNs (Grady et al., 2008), and
it has been suggested that ethics education may help relieve the problem
of moral distress (Lang, 2008). So that educators may better prepare
nurses for the challenges of advanced practice and the expanding role
and responsibilities of APNs, further research is needed to identify and
measure essential ethics education content and preferred teaching
methods.
References
American Association of Colleges of Nursing. (1996). The essentials
of master's education for advanced practice nursing. Washington,
DC: Author.
American Association of Colleges of Nursing. (1998). The essentials
of baccalaureate education for professional nursing practice.
Washington, DC: Author.
American Association of Colleges of Nursing (2006). The essentials
of doctoral education for advanced practice nursing. Retrieved from
www.aacn.nche.edu/DNP/pdf/Essentials.pdf
American Nurses Association. (2001). Code of ethics for nurses with
interpretive statements. Washington, DC: Author.
Bandura, A., Adams, N. E., & Beyer, J. (1977). Cognitive
processes mediating behavioral change. Journal of Personality and Social
Psychology, 35(3), 125-139.
Burkemper, J. E., DuBois, J. M., Lavin, M.A., Meyer, G., &
McSweeney, M. (2007). Ethics education in MSN programs: A study of
national trends. Nursing Education Perspectives, 28(1), 10-17.
Butz, A. M., Redman, B. K., Fry, S.T., & Kolodner, K. (1998).
Ethical conflicts experienced by certified pediatric nurse practitioners
in ambulatory settings. Journal of Pediatric Health Care, 12(4),
183-190.
Dubois, J. M., & Burkemper, J. (2002). Ethics education in U.S.
medical schools: A study of syllabi. Academic Medicine, 77(5), 432-437.
Godfrey, N. S., & Smith, K. V. (2002). Moral distress and the
nurse practitioner. Journal of Clinical Ethics, 13(4), 330-336.
Grady, C., Danis, M., Soeken, K. L, O'Donnell, P., Taylor, C.,
Farrar, A., & Ulrich, C. M. (2008). Does ethics education influence
the moral action of practicing nurses and social workers? American
Journal of Bioethics, 8(4), 4-11.
Ketefian, S. (1999). Ethics content in nursing education. Journal
of Professional Nursing, 15(3), 138.
Laabs, C.A. (2005). Moral distress among nurse practitioners in
primary care. Journal of the American Academy of Nurse Practitioners,
17(2), 76-84.
Laabs, C.A. (2007). Primary care nurse practitioners'
integrity when faced with moral conflict. Nursing Ethics, 14(6),
795-809.
Lang, K. R. (2008).The professional ills of moral distress and
nurse retention: Is ethics education an antidote? American Journal of
Bioethics, 8(4), 19-21.
Milton, C. L. (2004). Ethics content in nursing education:
Pondering with the possible. Nursing Science Quarterly, 17(4), 308-311.
Sulmasy, D. P., & Marx, E. S. (1997). Ethics education for
medical house officers: Long-term improvements in knowledge and
confidence. Journal of Medical Ethics, 23(2), 88-92. doi:
10.1136/jme.23.2.88
Sulmasy, D. P., Dwyer, M., & Marx, E. (1995). Knowledge,
confidence, and attitudes regarding medical ethics: How do faculty and
housestaff compare? Academic Medicine, 70(11), 1038-1040.
Sulmasy, D. P., Ferris, R. E., & Ury, W.A. (2005). Confidence
and knowledge of medical ethics among interns entering residency in
different specialties. Journal of Clinical Ethics, 16(3), 230-235.
Sulmasy, D. P., Geller, G., Levine, D. M., & Faden, R. (1990).
Medical house officers' knowledge, attitudes, and confidence
regarding medical ethics. Archives of Internal Medicine, 150(12),
2509-2513.
Sulmasy, D. P., Geller, G., Levine, D. M., & Faden, R. R.
(1993).A randomized trial of ethics education for medical house
officers. Journal of Medical Ethics, 19(3) 157-163.
Sulmasy, D. P., Terry, P. B., Faden, R., & Levine, D. M.
(1994). Long-term effects of ethics education on the quality of care for
patients who have do-not-resuscitate orders. Journal of General Internal
Medicine, 9(11), 622-626.
Wocial, L. D. (2008). An urgent call for ethics education. American
Journal of Bioethics, 8(4), 21.
About the Author At the time of the study, Carolyn A. Laabs, PhD,
MA, FNP-C, was assistant professor at Marquette University College of
Nursing, Milwaukee, Wisconsin. She currently holds the position of nurse
practitioner and clinic coordinator, Columbia St. Mary's Milwaukee,
St. Ben's Clinic for the Homeless. The author gratefully
acknowledges Drs. Russell Burck, Marie Hilliard, Daniel Sulmasy, and
Kathryn Schroeter for their assistance with this project. Funding was
provided by the Marquette Regular Research Grant. Contact Dr. Laabs at
claabs@wi.rr.com.
Table 1. Perceived Confidence Scale
DEGREE OF CONFIDENCE IN ONE'S ABILITY TO: MEAN SD
(5-point Likert scale; 1 = very low)
Recognize genuine ethical problem 4.26 0.69
Reach sound decision when facing problem 3.86 0.76
in clinical ethics
Give reasons for your decision 3.83 0.80
Determine consent is truly informed 3.97 0.83
Understand and manage ethical aspects of 3.55 0.85
cost containment
Know how to proceed when patient 3.54 1.06
is incompetent
Understand and manage ethical aspects of 3.64 1.15
care at end of life
Understand and manage ethical aspects of 3.41 1.04
financial incentives
Understand and manage ethical aspects of 3.25 1.23
reproductive health
Mean Confidence Scale Score 3.70 0.99
Table 2. Sample Characteristics (n = 172)
CHARACTERISTIC M NUMBER %
Age in years (range 25-65) 42
Gender
Female 166 96.5
Male 6 3.5
Area of practice
Adult NP 35 26.5
Nurse Midwife 25 18.9
Pediatric NP 18 16.7
Gerontological NP 14 10.6
Years as APN
New graduate 26 15.1
1-5 52 30.2
6-10 63 36.6
11-15 30 17.4
No answer 1 0.6
Currently in practice
Yes 129 75
Practice setting
Hospital inpatient 43 25
Hospital outpatient 31 18
Private MD office 29 16.9
Private APN practice 10 5.8
Ethics course during APN school 162 94
Quality of ethics education
Fair 51 29.7
Good 91 52.9
Table 3. Ethics Knowledge (n = 172)
KNOWLEDGE ITEMS (MULTIPLE CHOICE) NO. CORRECT % CORRECT
Definition of deontology 92 53.5
Legal hierarchy of surrogate decision 103 59.9
makers
Baby Doe laws 74 43.0
Euthanasia in the Netherlands 136 79.1
Definition of classic utilitarianism 11 6.4
Tarasoff case and duty to warn 92 53.5
Emergency transfusion and minor 34 19.8
Jehovah's Witnesses
Ethical principle of managed care 67 39.0
Tarasoff case and confidentiality 78 45.3
Patient Self-Determination Act and 158 91.9
Advance Directives
Determination of incompetence 65 37.8
Medicare, conflict of interest, and 84 48.8
Stark Amendments
Moral hierarchy of surrogate decision 53 30.8
makers
Emergency Medical Treatment and Active 154 89.5
Labor Act
Bouvia case and right to refuse 117 68.0
treatment
ANA position on capital punishment 94 54.7
Wyatt v Stickney and mental health 84 48.8
Role of ethics committee 146 84.9
Principle of cooperation 21 12.2
Conflict of interest and research 136 79.1
ANA Code of Ethics on intentionally 126 73.3
ending patient's life
Integrity in conduct and dissemination 137 79.7
of research
Identify conflict of interest in 148 86.0
clinical practice
Rights as justified claims made upon 12 7.0
others
Meaning of fiduciary and the APN/ 79 45.9
patient relationship
ANA Code of Ethics and principle of 161 93.6
accountability
Mean Total Correct 94.69 55.05
Mean Total Correct SD 45.47 26.43