Confidence and knowledge regarding ethics among advanced practice nurses.
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Laabs, Carolyn A.
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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.


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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.

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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
Table 1. Perceived Confidence Scale


(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

  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)


Definition of deontology                       92            53.5

Legal hierarchy of surrogate decision          103           59.9

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

Emergency Medical Treatment and Active         154           89.5
Labor Act

Bouvia case and right to refuse                117           68.0

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

Meaning of fiduciary and the APN/              79            45.9
patient relationship

ANA Code of Ethics and principle of            161           93.6

Mean Total Correct                             94.69         55.05

Mean Total Correct SD                       45.47         26.43
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