JOY HINSON PENTICUFF

CONCEPTUAL ISSUES IN NURSING ETHICS RESEARCH*

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ABSTRACT. Empirical studies that have attempted to describe nurses' ethical practice have used conceptual frameworks derived primarily from the disciplines of bioethics and psychology. These frameworks have not incorporated important concepts developed by nursing theorists over the past two decades. This article points out flaws in the past research frameworks and proposes a synthesis of ethical theory, nursing practice contexts, and empirical research methods to enrich theoretical development in nursing ethics. Key Words: ethics, ethics studies, nursing, theory development

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INTRODUCTION

This essay argues that nursing ethics research is impaired by inadequate conceptualization both of ethical practice and of factors that bear on ethical practice. The majority of ethics research in nursing has used a fragmented approach that unsuccessfully attempts to explain ethical practice in terms of a limited set of bioethical principles or in terms of nurses' moral development or role conceptions. The result of this conceptual constriction is that nursing ethics research has not provided an accurate account of nursing ethics. This limited description, in turn, impedes theory development in nursing ethics and impoverishes articulation of what is distinctive about it. To enrich theoretical development in nursing ethics, I propose an initial synthesis of ethical theory, foundational and emergent concepts of nursing,1 the context of nursing practice and empirical research methods. My approach will assume that the experiences of nurses and those who seek nursing care, in interaction with each other, provide an essential grounding for nursing ethics. I will first examine the conceptual frameworks used in nursing ethics research because these frameworks structure the questions Joy Hinson Penticuff, R.N., Ph.D., F.A.A.N., Associate Professor, School of Nursing, The University of Texas at Austin, 1700 Red River, Austin, Texas 78701, U.S.A. The Journal of Medicine and Philosophy 16:235-258,1991. © 1991 Kluwer Academic Publishers. Printed in the Netherlands.

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to be asked and systematically exclude questions that cannot be framed within the boundaries and conceptual resources the framework supplies (Munhall, 1982). My focus is on conceptual structures because conceptual models that guide research incorporate - implicitly or explicitly - perceptions of reality and specific assumptions and beliefs about the particular entities and processes of the domain under study (Kuhn, 1962). Past ethics research has resulted in the important recognition that ethical practice is complex, but the research frameworks used have lacked the integration of nursing's central concepts which might make that complexity more meaningful for the development of nursing ethics. I will then describe where nursing ethics research is occurring within both moral theory and nursing theory. Finally, I will suggest research efforts which may be important for the future development of nursing ethics, the larger field of biomedical ethics, and our general understanding of ethical decision making in clinical contexts. CURRENT CONCEPTUAL FRAMEWORKS IN NURSING ETHICS RESEARCH

The research frameworks used to explain and justify nursing ethical action in clinical practice draw on a variety of resources: a ready-made ethics derived from a circumscribed view of moral philosophy, a justice-oriented view of moral development adopted from developmental psychology, and role orientation concepts drawn from organizational psychology. The adequacy of each for nursing ethics inquiry is questionable. Bioethical Theory as a Research Framework

Studies that employ a bioethical principles framework attempt to explain nurses' ethical practice or ethical decision making in terms of broad principles such as respect for autonomy, beneficence, and justice. Bioethical principles are important to our understanding of nursing ethical practice, but there are three major limitations inherent in their use as explanations of ethical judgment or behavior, i.e., in their use in descriptive ethics. The first limitation is that the presumed authority of bioethical principles prohibits examination of other variables known to influence ethical practice (Crisham, 1981; Ketefian, 1989a; Mur-

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phy, 1977; Martin and Penticuff, 1989; Penticuff, 1990b). Garritson's (1987/88) research on nurses' ethical decisions is a good example of a study incorporating a principles-based approach. The principles of distributive justice, respect for autonomy, and beneficence were used to categorize the nurse subjects' decisions but could not consistently account for nurses' choices and how ethical choice varied according to situational factors. On the other hand, some researchers have combined a principles framework with a broad conceptualization of the practice environment and studied these variables concurrently. An example of how principles can be studied in light of contextual influences and values is Davis' (1989) research on clinical nurses' resolution of dilemmas in informed consent. The study examined the relative importance of principles of respect for autonomy and beneficence, restraints on nurses' and patients' options engendered by hospital environments, and the philosophical perspectives - empiricist vs. personalistic - of the nurses interviewed. The importance of examining variables other than ethical principles is supported by Davis' finding that "Such notions as 'free choice' or l?eing there for the patient' [beneficence] were perceived as rarely possible because the system itself was not patient-centered..." (p. 66). Davis' framework allowed the realization that an ethical principles approach does not adequately explain all of the factors that influence nurses' decision making in ethical dilemmas. Another problem with current bioethical frameworks is that the commonly used principles do not reflect the breadth and diversity of concepts available in the general ethics literature. There are few logical links between much of moral philosophy and the circumscribed forms of bioethical theory from which most of current nursing ethics research frameworks are derived. The literature in biomedical ethics has emphasized four primary principles beneficence, respect for autonomy, justice, and nonmaleficence (Beauchamp and Childress, 1989; Engelhardt, 1986; Fowler, 1989). An example of this approach is Gortner and Zyzanski's (1988) research that attempted to identify which principles predominated in patients who had decided to undergo cardiac surgery. Gortner and Zyzanski limited the response options to autonomy and a combined principle of beneficence/nonmaleficence, presupposing that patients' decisions were determined by only these two points of moral justification. No examination was

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made of the patients' consideration of other values or notions of fairness in the use of scarce health care resources. Yet neither autonomy nor beneficence provided an adequate description of the moral system actually used by the patients to make judgments about whether to undergo cardiac surgery. If nursing ethics research is based on frameworks that rely on only three or four formal principles and other variables are not studied, the importance of contextual influences, values, and other systems of moral justification in ethical decision making may be in danger of misapprehension or being missed entirely. Ethical principles recently have been criticized by Clouser and Gert (1990) as only a collection of matters for moral consideration that lack any systematic relationship to each other, sometimes conflict, and cannot guide action. Autonomy, beneficence, nonmaleficence and justice are presented in major bioethics texts (e.g., Beauchamp and Childress, 1989) as though they are logically derived from harmonious overarching ethical theories, when in fact the principles contain internal inconsistencies and the theories they purport to synthesize are themselves discordant. Clouser and Gert maintain that because principles are not firmly established and justified, agents are deceived in thinking of principles as providing ethical imperatives. They note, "If the principle is not a clear, direct imperative at all, but simply a collection of suggestions and observations, occasionally conflicting, then he [the agent] will not know what is really guiding his action nor what facts to regard as relevant nor how to justify his action" (pp. 222-223). Clouser and Gert's criticisms seem relevant to studies that find significant violations of traditional ethical principles in nursing practice. One such example is a study (Shelly, Zahorchak, and Gambrill, 1987) of aggressiveness of nursing care for patients who had requested no resuscitation. Findings indicate that while the degree of aggressiveness did decrease under Do Not Resuscitate (DNR) orders, 28% of the nurses sampled would admit the DNR patient to an intensive care unit. Although the principle of respect for autonomy was not directly examined in the Shelly et al. study, it is interesting that respect for patient autonomy was not a clear guide for nursing decision making. Further examination of the reasons why nurses might feel justified in overriding patient autonomy, or of the situations in which disregard for patients' decision making prerogative occurred, could shed more light on the process by

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which ethical principles are violated in nursing practice and whether the principles actually carry the moral authority ethics theorists ascribe to them. A third problem with current bioethical theory is that it often presents a prescriptive, formal approach by which principles are applied in a process-dominated manner termed 'formula ethics' (White, 1983). As Yeo notes, formula ethics ...reduces ethical practice to correct technique, and promotes an overly mechanical (and therefore insensitive) comportment to ethical problems. The moral situation of nursing is squeezed into imported categories that are applied in a top-down fashion. The danger is that the experience of nursing will be distorted or otherwise denied (1989, p. 39).

White's criticism of 'formula ethics' is congruent with Duffs (1987) discussion of 'distant' versus 'close-up' ethics. Distant ethics emphasizes abstract ethical principles and the rules by which these may be applied, while close-up ethics emphasizes the primacy of human relationships and acknowledges the importance of feelings, family values, and individual and family conscience. An example of research in which the principles of autonomy, beneficence, and nonmaleficence were studied in combination with examination of feelings, values, and conscience is the work of Akerlund and Norberg (1985). Their study described nurses' and nurse aides' experience of feeding severely demented patients. Double bind conflicts were experienced when nurses considered ethical principles, yet were unable to apply these principles in a manner which produced resolution of the ethical bind. Clouser and Gert's assertion that principles cannot guide action because of their lack of hierarchical order is strikingly borne out by the Akerlund and Norberg study. Numerous studies (Ketefian, 1981a, 1981b, 1985; Gaul, 1987) have measured nursing ethical practice with Ketefian's (1989b) 'Judgments about Nursing Decisions' instrument, which uses principles derived from the Code for Nurses (American Nurses' Association, 1985) as the standard for measuring nurses' hypothetical moral practice. Research using this instrument arguably falls within the category of 'formula ethics' research, because it applies principles directly to hypothetical cases without allowing consideration of any other factors that might enter into ethical decision making. As Fry (1987) notes, instruments based on

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interpretation of the ANA Code of Ethics and bioethical principles need to be reconsidered because these theoretical structures may not accurately represent the foundations of nurses' moral decision making. Bioethical theory frameworks are valuable to nursing ethics research and cannot be discarded, but there must also be recognition that nursing ethical practice cannot be explained solely in terms of abstract principles. A more adequate ethical framework is required which will encompass additional aspects of moral judgement and justification. Moral Development Theory as a Research Framework

Typically, studies using this type of framework (Mayberry, 1986; Munhall, 1980; dejong, 1984/85; Akerlund and Norberg, 1985; Crisham, 1981; Ketefian, 1981b) correlate nurses' self-reported ethical choices with their levels of moral reasoning as measured by a moral reasoning instrument, usually derived from Kohlberg's (1984) moral development framework. Yet it is not certain that moral development is predictive of ethical practice. In fact, study findings are conflicting and have demonstrated no consistent relationship (Ketefian, 1988,1989a). Although the nursing literature on moral development makes an implicit assumption that persons at higher stages of moral reasoning are more likely to act morally than those at lower stages, there is no body of empirical evidence to support this notion (Ketefian, 1988). Some nursing theorists have suggested, based on Kohlberg's theory, that nurses at the principled stage of moral reasoning would be likely to uphold norms only to the extent that the norms serve human values (Munhall, 1980), and to act as morally responsible agents and patient advocates (Murphy, 1977). There has been no published empirical study of these assumptions. On the other hand, Blasi's (1980) extensive review of moral action suggests that moral reasoning and moral action are related, depending on the outcome criteria used. Some of the problems in the empirical study of the moral reasoning-behavior relationship may have to do with the complexity of the linkage. Moral behavior is conceptualized by Schlaefli, Rest, and Thoma (1985) as composed of four elements, with moral reasoning being but one: (1) moral sensitivity to the consequences of one's acts on the

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welfare of others; (2) moral reasoning as to the proper course of action; (3) motivation to place morality above other considerations; and (4) persistence and practical strategy for implementation of the moral decision. Ketefian's research (1981a) has presented some evidence for a relationship between the level of moral development and hypothetical ethical practice. She also found a positive relationship between critical thinking and moral reasoning (1981b), but concludes (1988) that the relationship between moral reasoning and moral behavior remains unclear because of lack of conceptual clarity about the phenomena of moral reasoning and moral practice. She notes that factors that potentially influence moral practice are so complex that multivariate research strategies and multiple measures are required if these factors are to be effectively explained. Thus far, empirical nursing ethics inquiry has not reached this level of development. A second, and perhaps more serious, problem with Kohlbergian moral development frameworks is that they use a justice-oriented standard of moral development which has been criticized for its abstractness (Friedman, 1987; Huggins and Scalzi, 1988), its impartiality (Blum, 1988; Benner, 1990) and for not giving sufficient weight to the significance of caring relationships in moral choices and judgments (Gilligan, 1982, 1987; Ornery, 1989). Kohlberg's theory describes stages and processes in moral reasoning, as opposed to the content of moral choice. The higher levels are characterized by adoption and impartial application of ever more abstract universal principles, with justice being conceptualized as the central core of morality. It has been widely used as the conceptual definition of moral reasoning in nursing ethics research. From a total of 41 nursing ethics studies published between 1983 and 1987, 15 were based on Kohlberg's theory (Ketefian, 1988,1989a). Friedman (1987) criticizes the excessive abstractness of Kohlberg's justice orientation because of its omission of morally relevant context details. She argues that neglect of context and human interconnection prevented Kohlberg from recognizing fundamental moral problems in the famous Heinz story. The story, used by Kohlbergian researchers to elicit moral judgments from subjects, depicts a pharmacist who insists on charging an exorbitant price for a drug needed to save the life of Heinz7 wife. The question presented to Kohlberg's research subjects is whether

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Heinz would be justified in stealing the drug. But Friedman points out that Kohlberg's interpretation of the moral dilemma ignores the context of the problem and thereby avoids confronting the morality of the larger social system in which needy persons can die for want of a drug; begs the question of who are the significant moral agents in the case; is biased in giving only Heinz's perspective, and ignores implications of the relationship between Heinz and his wife. Indeed, the inclination to view moral problems within the context of relationships makes a poor fit with a Kohlbergian ethic of justice which demands the use of context-independent rules (Huggins and Scalzi, 1988). Nurses (Ornery, 1989; Nokes, 1989; Huggins and Scalzi, 1988), and moral philosophers (Okin, 1989; Adler, 1989; Card, 1988; and Blum, 1988) have also questioned the adequacy of the impartialist approach inherent in Kohlberg's justice orientation. Nurses claim that Kohlberg's theory does not portray the moral elements of caring and connectedness which seem central to nursing practice. As Benner (1990) notes, the moral dimensions of caring in nursing require attention to the local and the specific, the particular and the concrete, not just the abstract and the theoretical. Some nurses even contend that the impartialist approach required by a justice orientation is antithetical to the caring perspective that has emerged as a significant aspect of nursing ethics within the past decade (Huggins and Scalzi, 1988; Ornery, 1989). The major published studies using the Kohlbergian justice framework are those of Ketefian (1981a, 1981b), Crisham (1981), Munhall (1980) and Mustapha and Seybert (1989). All of these studies employ moral reasoning instruments which reflect Kohlberg's theoretical approach and all ask nurses to respond to hypothetical ethical dilemmas. There are no published studies in which scores on measures of moral reasoning have been correlated with actual nursing behaviors in clinical practice. The work of Carol Gilligan (1982,1987) has stimulated a rethinking of the appropriateness of Kohlberg's theory as the standard by which moral reasoning in nursing is to be evaluated. Gilligan argues that care and responsibility within personal relationships are just as necessary to good moral thinking as are abstract reasoning, autonomy and concern for equality. Gilligan points out that Kohlberg's research was conducted primarily with males, and the responses of the females included in his research were discounted when their responses did not confirm results obtained

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from males. Her work indicates that female patterns of moral development emphasize a care perspective, rather than a perspective governed by impartial abstract principles (Gilligan, 1987). The impartial application of abstract principles emphasized by Kohlberg and the caring, connected, context-bound values and strategies found in the judgments of women are distinguished by different conceptions of the self, human relationships, moral conflict, conflict resolution, and different perceptions of good and harm (Gilligan, 1987). Gilligan concluded that care perspectives define the self as embedded in relationships, while appeal to impartial, abstract principles conceive the self as rational, unemotional, and autonomous (Gilligan, 1982; Card, 1988). Although Gilligan's focus on context and responsibility in relationships seems congruent with traditional nursing values, at present there are no published reports of nursing studies which have used her moral development framework. The lack of studies is probably due to the fact that there is not an easily administered, reliable, and valid measurement tool available that reflects Gilligan's developmental approach. Role Conception as a Research Framework

Studies using a role conceptions framework hypothesize a relationship between the nurse's conception of role - either professional or bureaucratic role orientations - and ethical practice (Ketefian, 1985). Theoretically, nurses who see their role as primarily upholding professional standards and ideals will practice more ethically than nurses who hold a less professional role view. Nurses who hold a bureaucratic role view place organizational interests above patient interests and are hypothetically less likely to uphold professional standards and ideals than their professionallyoriented colleagues. However, a problem in this attempt to link professional role conception with ethical practice is that only about 25% of nurses sampled were categorized as holding clearly professional role conceptions. Approximately half of those sampled simultaneously held both bureaucratic and professional role conceptions, so that the explanatory power of these role concepts is limited (Ketefian, 1985; Katz and Kahn, 1966). Ketefian (1985) notes "it is an oversimplification to view professionals in bureaucracies as either professionally oriented or bureaucratically oriented" (p. 253). Role conception alone may not explain moral

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behavior and hence, may not be an adequate framework for nursing ethics research. Another difficulty with ethics research employing role conceptions is that this research has not concurrently examined the context within which role conceptions are enacted. It has not taken into account the possible influence of organizational factors on the modeling and reinforcement of roles. The organizational and administrative theories from which these role concepts are derived specifically place role conceptions within the larger organizational climates of which they are a part (Katz and Kahn, 1966). Thus, while Ketefian's (1985) data are interesting, it is difficult to see their meaning when role concepts are isolated from their complementary contextual variables. Ketefian's (1985) suggestion that a professional role orientation may be dysfunctional within the realities of work environments is consistent with the findings of other studies that indicate that nurses may not have sufficient autonomy to implement a professional role orientation. For example, in a study of critical care staff nurses, organizational characteristics such as workload, staffing patterns, and quality of relationship with the head nurse were important determinants of nurses' perceived autonomy and sense of control over their work (Alexander, Weisman, and Chase, 1982). Numerous studies of nurses' authority in hospitals have concluded that nurses do not have the autonomy and organizational influence necessary to carry out their professional responsibilities for patients (Institute of Medicine, 1982; American Academy of Nursing, 1983; Dennis, 1983; Prescott and Dennis, 1985). Despite the limitations of the role conceptions framework, Ketefian's (1985) research in this area has contributed to a better appreciation of the theoretical relevance of bureaucratic and professional role orientations to nursing ethics. Ketefian also notes that examination of environmental and organizational context has yielded promising results, but that these studies make up only a small proportion of empirical ethics research. INTEGRATED ETHICS RESEARCH

Integrated research frameworks utilize theories of nursing and theories of ethics to understand the interchanges between nurses and those in need of nursing care. It is acknowledged that no one

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research study can hope to measure comprehensively all of the possible components of an integrated framework. But studies can be designed that recognize the importance of each component so that meaningful progress can be made in nursing ethics research. Nursing ethics studies that explore, in whole or in part, an integrated approach are reviewed briefly below. The discussion is organized around traditional foundational concepts of nursing person, nursing, environment, and health - and emerging constructs which are important to a rich concept of nursing. Persons in Health and Illness

Essential elements of this concept include a comprehensive view of the person as a spiritual being, a member of a family and a community, and a unity of body and mind (Rickelman, 1971; Leonard, 1989; Rogers, 1970; Roy, 1984; King, 1971). As individual human selves, persons are actively creating, acting on the environment and being acted on through transitions and relationships, and are open to and changed by influences and forces known and unknown. The person is an independent and dependent worldly actor-sufferer, in a dynamic rather than static relationship with the world. The person is not merely a mature, rational, decisionmaking self, but is also growing, realizing, and at all times vulnerable to worldly and bodily vicissitudes - a self striving to realize life goals but vulnerable to losses (Donnelley, 1988; Leonard, 1989). Pinch (1989), Gortner and Zyzanski (1988) and Mishel and Murdaugh's (1987) descriptive data about patients' and families' feelings, perceptions, beliefs and values through the experience of illness are potentially relevant to normative ethical theories about providing good and avoiding harm in health care. Dennis' (1987) study of dimensions of patient control is important to normative nursing ethics because it identifies concepts and specific nurseactions - substantive content - relevant to the affirmation of patient autonomy during hospitalization. All conceptualization of health and illness is value laden. In nursing, the definition provided in the American Nurses' Association Social Policy Statement is widely accepted: "Health is a dynamic state of being in which the developmental and behavioral potential of an individual is realized to the fullest extent" (1980, p. 5). In illness, various forces produce some level of disrup-

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tion, either temporary or permanent, of those capacities by which the person conceives of life goals and moves toward their realization. Benner's (1985) work explored the human experience of illness and points out that meanings given by the patient to experiences in illness engender integrative processes - faith and optimism, on the one hand, and surrender and depression on the other - and these processes have much to do with deterioration or with healing. Theoretical constructs presented by Benner (1985) and Holmes (1989) can enrich nursing ethics research frameworks through contribution of both concepts and data about goods and harms in human experience. Similarly, Peterson's (1988) case studies of patients who refused life-sustaining therapies is of great significance to our understanding of patient experiences and contexts in patient ethical decision making. Battenfield's (1984) conceptual description of suffering is another example of study of a construct highly relevant to evaluation of providing good and avoiding harm in nursing. The patient's sense of self in illness has been shown to influence the patient's deliberations in giving informed consent. Sirva (1985) and Evans (1989) have examined how illness or despair can disrupt cognitive processes and impair decision making ability. Such studies provide substantive content essential to nurses' enactment of ethical obligations to respect human autonomy, and raise legitimate questions about the limits to autonomy imposed by illness. Nursing and Nurse-Patient Transactions

In this conceptual domain, the nature of nursing, what it means to be a nurse, and essential features of nurse-patient transactions are examined. The ethical goals of nursing relate directly to human needs, and these goals are either met or not within nurse-patient transactions. Although Gadow (1990), Benner (1990, 1985), Leininger (1988) and Watson (1985,1988) have written extensively about the primacy of the nurse-patient relationship to nursing ethics, very little in empirical nursing ethics research has examined the transactions within this relationship or the contexts within which they occur. Much progress has been made in defining nursing, but little research attention has been paid to the morally relevant aspects of the experience of performing nursing

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actions within health care environments. It is interesting that nursing's traditional values of altruism and service tend to separate individual nurses from the sympathetic conceptualization of humankind held by the discipline. What dominates nurses' self-conceptualization in the professional literature is a view of the nurse as giving, caring, advocating for others; always competent, capable, and adequate to the task. Yet studies of nurse burnout (Jacobson, 1978; American Hospital Association, 1987; Bartz and Maloney, 1986; Cameron, 1986; Cronin-Stubbs and Rooks, 1985; Keane, Ducett, and Adler, 1985) reveal that disillusionment with the work of nursing, apathy in the face of patient need, moral distress and moral outrage can be a reality.2 Nursing ethics research that examines how moral integrity is maintained or eroded is significant to understanding nursing ethical practice because if nurses do not have the will to practice ethically, the entire enterprise of nursing as a helping profession is in jeopardy. Jacobson's (1978) study of nurse burnout in neonatal intensive care revealed that unresolved ethical dilemmas produced the most intense levels of stress experienced by these nurses. The demands upon nurses to provide competent, compassionate care can result in moral distress if nurses are unable to meet their own or others' expectations. Phillips and Rempusheki (1986) studied the human psychological and material elements that go into caregiving. This research is relevant to nursing's evaluation of the adequacy of resources for nurses who work directly with patients whose care is long-term and demanding. The moral issue turns on whether it is right to consider nurses obligated to provide care for which psychological and/or material resources are unavailable. Research on moral distress conducted by Wilkinson concluded, "Those nurses who are unable to cope with moral distress and who leave bedside nursing seem to be those who are most aware of, and sensitive to, moral issues, and who feel a strong sense of responsibility to patients and for their own actions" (1986/87, p. 27). Perhaps one of the most acclaimed recently emergent issues in nurse-patient transactions is the concept of caring. Carper (1979) states, "To be concerned with the 'whole person' and to practice with consideration and sensitivity for the integrity of the human self is basically an ethical injunction. Caring, as a professional and

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personal value, is of central importance in providing a normative standard which governs our action and our attitudes toward those for whom we care" (pp. 11-12). Benner (1990) argues that "a biomedical ethics based on problem-oriented issues of iatrogenesis and questions of autonomy, rights, justice and paternalism... cannot provide a positive statement of the good and must be augmented by an ethic of care" (p. 1). Despite the acknowledged importance of the value of caring in nurse-patient relationships, Stevenson's (1989) review of research studies reveals no systematic investigation of caring within an ethics research framework. Recent interest in and evolution of models of caring (Benner, 1988, 1990; Leininger, 1988; Watson, 1985; Fry, 1989a, 1989b; Valentine, 1989) are encouraging and important trends which may be foundational to emerging nursing ethics. Philosophical analyses of caring as a central value in nursing ethics have been carried out (Fry, 1989a, 1989b; Benner, 1990; Griffin, 1983) but this theoretical work has not been used in the empirical study of caring in the nurse-patient relationship. Similarly, the ethical role of the nurse as patient advocate has been described (Gadow, 1980, 1988; Curtin, 1979; Penticuff, 1989, 1990a; Corcoran, 1988), but little empirical research has been conducted in this area. Thus, examination of the concept of nursing and what it means to be a nurse reveals that the scope and nature of nursing practice are becoming increasingly more clearly articulated by nursing theorists, but exploration of the phenomenology of providing good and avoiding harm in nurse-patient transactions has barely begun. On the other hand, there is increasing consensus (Fry, 1989b; Benner, 1988; Watson, 1988) that it is within the nursepatient relationship that important foundations of nursing ethics will be derived. Environment and Health

Nursing conceives of humans as influencing and being influenced by environments (Stevens, 1989; Newman, 1986). The self does not exist in isolation, but is nurtured or impaired by an animate and inanimate universe of intimates, colleagues, acquaintances, strangers, and community and global influences. Patients' self determination within health care settings is a critically important variable within the environment concept. Not

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only does illness diminish patients' power to influence their world, but the health care setting itself frequently takes away patient control. An example of research in this area is Kjervik and Grove's (1988) examination of consent in unequal power relationships. Issues of control are relevant to nursing ethics, not only in terms of studies of informed consent, but also in terms of the everyday respect for patient autonomy and dignity so often violated in health care settings. The inequality of social status, education, medical expertise, and economic status in nurse-patient and physician-patient relationships in health care settings often results in patients' abdication of decision making or their sabotage of medical plans to which they did not contribute. The diverse hospitals, clinics, community and home health agencies, hospices, health advocacy organizations, health policy institutes and resource allocation agencies within what we term 'the health care system' should be regarded as the environment in which nursing ethical practice occurs. An extensive review of factors that influence delivery of health care (Hinshaw and Atwood, 1983) and the nursing administration perspective articulated by Jennings and Meleis (1988) present concepts relevant to patient-nurse-health care environment interactions which have potential utility for nursing ethics research. Concepts within these frameworks allow description of the influences of context on patient and nurse ethical decision making, patient autonomy, nurse ethical integrity, and organizational prevention and resolution of ethical dilemmas. Prescott and Dennis' (1985) study of power and powerlessness in hospital nursing departments and Alexander, Weisman, and Chase's (1982) research on determinants of staff nurses' perceptions of autonomy within clinical contexts have implications for nursing ethics research regarding the ability of nurses to be moral agents within health care institutions. Some studies document the influence of organizational factors such as institutional policies, administrative support for nurses' involvement in decisions, and institutional resources on nurses' ethical decisions (Davis, 1989; Martin and Penticuff, 1989; Penticuff, 1990b). Conflicts between personal values and the requirements of administrative policy were described in the research of Savage, Cullen, Kirchoff, Pugh and Forman (1987). The general conclusion from studies (Dennis, 1983; Mayberry, 1986; Prescott and Dennis, 1985) and reflection about nurses' prerogatives, as well as independent functioning in

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critical care and ambulatory care settings, is that nurses' moral agency is impeded by institutional limitations of their power and by the divided loyalties of the nurse to patients, nursing peers, physicians, and institutions. RESEARCH RELEVANT TO THE FUTURE DEVELOPMENT OF NURSING ETHICS

If we agree that the foundations of nursing ethics come from the experiences of nurses and those who seek nursing care, in interaction with each other, it is necessary to focus inquiry about nursing ethics on the transactions of patients and nurses within health care contexts. Most of nursing practice occurs within dyadic human relationships, and it is within these relationships that the moral goals of nursing are realized or are lost. It is also from these relationships that the truest perspective of providing human good and avoiding human harm is derived. The future development of nursing ethics will be aided if research efforts employ comprehensive frameworks which integrate the significant concepts described earlier and address the relational, institutional, and political environments within which nursing is practiced. For example, a more appropriate and comprehensive ethical theory for nursing ethics should be broader in scope and more detailed regarding the relationships among concepts and processes within its boundaries. An overarching ethical theory might encompass (1) virtue theory; (2) obligations in helping relationships and professional roles; (3) caring theory; (4) values, conscience, affect; and (5) contextual influences. This type of theory might also set out and justify the processes by which elements within the theory will be reconciled with each other in cases of conflict and such a theory could provide a more accurate account of nurses' moral practices. Since the institutional and political environments within which nursing is practiced generate ethical conflicts for many nurses, a comprehensive nursing ethics theory should be capable of addressing the following types of questions: Do practice environments modify nurses' normative obligations? What are nurses' options as moral agents in hospitals, nursing homes, and community settings? What resources exist in the health care setting that either enhance or impede nurses' moral agencies? How adequate are

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institutional resources for resolving ethical dilemmas in nursing practice? Research on how the health care setting promotes or impedes nurses' ethical decision making is important not only to the development of nursing ethics but to the discipline of bioethics, in general. Finally, nursing ethics research should provide data for descriptive ethics as well as for normative ethics. Descriptive ethics research can increase our knowledge about what it means to provide good and avoid harm within helping relationships. This knowledge can then inform normative ethical theory concerning what ought to be done to fulfill moral responsibilities in health care. Descriptive ethics also provides substantive content which normative judgments must take into account if ethics is to enrich human life. How humans understand good and harm, and what constitutes their sense of well-being within health care relationships, are examples of substantive content that underlie many normative judgments about nursing practice. However, to provide appropriate data for descriptive and normative ethics in nursing, research efforts need to employ a 'rich concepf of nursing rather than the impoverished concept which has typified past research efforts. A 'rich concept' of nursing takes into account the complexity of the nursing role within practice environments and the goals and values of nursing as they relate to human needs. In my view, the goals of nursing are to (1) relieve human suffering and vulnerability in illness; (2) support the restoration and maintenance of health; and (3) preserve human integrity. Research efforts that incorporate these goals will study anxiety, confusion, pain, fatigue, and the erosion of the sense of self and their influences on patient well-being during times of illness. Quality of life in terms of the patient7s movement toward realization of his or her values, goals, options, and desires is another potential area for research efforts that employ a 'rich concept' of nursing. SUMMARY

Analysis of nursing ethics research to date reveals the use of a limited range of conceptual frameworks that are relatively uninformed about nursing concepts and their development over the past twenty years. A synthesis of ethical theory and research methods with the foundational and emergent concepts of nursing

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and the context of nursing practice is proposed as an initial framework for future nursing ethics research. Essential elements of such a research agenda include: conceptual and operational definitions of human caring; conceptual and operational definitions of providing good and avoiding harm in nurse/patient transactions; empirical study of patient and nurse moral agencies within health care settings; and empirical study of the modifying effect of contextual factors on normative ethical standards in practice environments. When research efforts include these elements, the development of nursing ethics will advance and the discipline of bioethics will be enriched. NOTES * The author wishes to acknowledge the thoughtful assistance of Sara Fry and Laurence McCullough in the preparation of this manuscript. This manuscript was prepared while the author was a Fellow at the Center for Ethics, Medicine and Public Issues, Baylor College of Medicine, supported by a National Research Service Award Senior Fellowship, National Center for Nursing Research, National Institutes of Health, and a University of Texas at Austin Faculty Research Grant. 1 The foundational concepts of nursing identify the structure of the discipline. Donaldson and Crowley (1978) note, 'Typically, disciplines have evolved as a consequence of a distinct perspective and syntax, which determine what phenomena or abstractions are of interest, in what context such phenomena are to be viewed, what questions are to be raised, what methods of study are to be used, and what canons of evidence and proof are required" (p. 114). The basic structural conceptualizations of nursing provide the scope and boundaries of the discipline, while the syntax provides procedures for verifying and falsifying truth claims. The foundational concepts which demarcate nursing are person, environment, nursing, and health-illness (Walker, 1986; Fawcett, 1978, 1984; Donaldson and Crowley, 1978; Bush, 1986; Barnard, 1980; Newman, 1986; Chinn and Jacobs, 1983; Carper, 1978). Emergent concepts of nursing are those which assist understanding of human responses to illness and human striving toward health. Such concepts as quality of life, suffering, and self actualization are potentially significant to nursing ethical theory. 2 Moral distress is defined by Wilkinson (1986/87) as "the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated by that decision" (p. 16). Her research found that moral distress has situational, cognitive, and action dimensions as well as the feelings dimension. The strength of the feelings is influenced by the degree to which the nurse

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identifies with the patient, and by her/his perception of the nursing role in terms of passive rule-following vs. active decision making. REFERENCES Adler, J.E.: 1989, 'Particularity, Gilligan, and the two-levels view: A reply7, Ethics 100(1), 149-156. Akerlund, B.M., and Norberg, A.: 1985, 'An ethical analysis of double bind conflicts as experienced by care workers feeding severely demented patients', International Journal of Nursing Studies 22,207-216. Alexander, C.S., Weisman, C.S., and Chase, G.A.: 1982, 'Determinants of staff nurses' perceptions of autonomy within different clinical contexts', Nursing Research 31(1), 48-52. American Academy of Nursing: 1983, 'Magnet hospitals: Attraction and retention of professional nurses', Kansas City, MO: American Nurses' Association. American Hospital Association: 1987, 'Moral distress in nursing', Hospital Ethics 3(4), 1-4. American Nurses' Association: 1985, Code for Nurses with Interpretive Statements, Kansas City, Missouri. American Nurses' Association: 1980, ANA Social Policy Statement, Kansas City, Missouri. Barnard, K.: 1980, 'Knowledge for practice: Directions for the future', Nursing Research 29,208-212. Bartz, C, and Maloney, J.P.: 1986, 'Burnout among intensive care nurses', Research in Nursing and Health 9(2), 147-153. Battenfield, B.L.: 1984, 'Suffering - A conceptual description and content analysis of an operational schema', Image: The Journal of Nursing Scholarship 16(2), 36-41. Beauchamp, T.L., and Childress, J.F.: 1989, Principles of Biomedical Ethics, Third Edition, Oxford University Press, New York. Benner, P.: 1985, 'Quality of life: A phenomenological perspective on explanation, prediction, and understanding in nursing science', Advances in Nursing Science 8(1), 1-14. Benner, P.: 1988, The Primacy of Caring, Addison-Wesley, Menlo Park, CA. Benner, P.: 1990, The moral dimensions of caring', in J.S. Stevenson and T. TrippReimer (eds.): Knowledge about Care and Caring, American Academy of Nursing, Kansas City, Missouri, pp. 5-17. Blasi, A.: 1980, 'Bridging moral cognition and moral action: A critical review of the literature', Psychological Bulletin 88,1-45. Blum, L.A.: 1988, 'Gilligan and Kohlberg: Implications for moral theory', Ethics 98(3), 472-191. Bush, H.A.: 1986, 'Models for nursing', in L.H. Nicholl (ed.): Perspectives on Nursing Theory, Little, Brown and Co., Boston, pp. 377-383.

254

Joy Hinson Penticuff

Cameron, M.: 1986, The moral and ethical component of nurse burn-out', Critical Care Management Edition 17(4), 42B-42E. Card, C: 1988, 'Women's voices and ethical ideals: Must we always mean what we say?', Ethics 99(1), 125-135. Carper, B.A.: 1978, 'Fundamental patterns of knowing in nursing', Advances in Nursing Science 1(1), 13-23. Carper, B.A.: 1979, The ethics of caring', Advances in Nursing Science 1(3), 11-19. Chinn, P.L., and Jacobs, M.: 1983, Theory and Nursing: A Systematic Approach, Mosby, St. Louis. Clouser, K.D., and Gert, B.: 1990, 'A critique of principlism', The Journal of Medicine and Philosophy 15(2), 219-236. Corcoran, S.: 1988, Toward operationalizing an advocacy role', Journal of Professional Nursing 4(4), 242-248. Crisham, P.: 1981, 'Measuring moral judgment in nursing dilemmas', Nursing Research 30(2), 104-110. Cronin-Stubbs, D., and Rooks, C.A.: 1985, The stress, social support, and burnout of critical care nurses: The results of research', Heart and Lung 14(1), 31-39. Curtin, L.L.: 1979, The nurse as advocate: A philosophical foundation for nursing', Advances in Nursing Science 1(3), 1-10. Davis, A.J.: 1989, 'Clinical nurses' ethical decision making in situations of informed consent', Advances in Nursing Science 11(3), 63-69. dejong, A.F.: 1984/85, The relationship of moral reasoning and perceived autonomy at work to ethical judgments among female registered nurses', Dissertation Abstracts International 46(792B). Dennis, K.E.: 1983, 'Nursing's power in the organization: What research has shown', Nursing Administration Quarterly 8,47-57. Dennis, K.E.: 1987, 'Dimensions of client control', Nursing Research 36(3), 151-156. Donaldson, S.K., and Crowley, D.M.: 1978, 'The discipline of nursing', Nursing Outlook, February, 113-120. Donnelley, S.: 1988, 'Human selves, chronic illness, and the ethics of medicine', Hastings Center Report 18(2), 5-8. Duff, R.S.: 1987,' "Close-up" versus "distant" ethics: Deciding the care of infants with poor prognosis', Seminars in Perinatology 11,244-253. Engelhardt, H.T.: 1986, The Foundations ofBioethics, Oxford University Press, New York. Evans, D.: 1989, The psychological impact of disability and illness on medical treatment decisionmaking', Issues in Law and Medicine 5(3), 277-299. Fawcett, J.: 1978, The relationship between theory and research: A double helix', Advances in Nursing Practice 1(1), 49-62. Fawcett, J.: 1984, The metaparadigm of nursing: Present status and future refinements', Image: The Journal of Nursing Scholarship 16(3), 84-87. Fowler, M.D.: 1989, 'Ethical decision making in clinical practice', Nursing Clinics of North America 24(4), 955-965.

Conceptual Issues in Nursing Ethics Research

255

Friedman, M.: 1987, "Care and context in moral reasoning7, in E.F. Kittay and D.T. Myers (eds.), Women and Moral Theory, Rowman and Littlefield, Totowa, N.J., pp. 190-204. Fry, S.T.: 1987, 'Research on ethics in nursing: The state of the arf, Nursing Outlook 35(5), 246. Fry, S.T.: 1989a, Toward a theory of nursing ethics', Advances in Nursing Science \\(.±), 9-22. Fry, S.T.: 1989b, The role of caring in a theory of nursing ethics', Hypatia 4(2), 88-103. Gadow, S.: 1980, 'Existential advocacy: Philosophical foundation of nursing7, in S.F. Spicker and S. Gadow (eds.), Nursing Images and Ideals, Springer Publishing Co., New York, pp. 79-101. Gadow, S.: 1988, 'Covenant without cure: Letting go and holding on in chronic illness', in J. Watson and M.A. Ray (eds.): The Ethics of Care and the Ethics of Cure, National League for Nursing Publication #15-2237, New York, pp. 5-14. Gadow, S.: 1990, The advocacy covenant: Care as clinical subjectivity', in J.S. Stevenson and T. Tripp-Reimer (eds.), Knowledge about Care and Caring, American Academy of Nursing, Kansas City, Missouri, pp. 33-40. Garritson, S.H.: 1987/88, 'Ethical decision making patterns', Journal of Psychosodal Nursing 26(4), 23-29. Gaul, A.L.: 1987, The effect of a course in nursing ethics on the relationship between ethical choice and ethical action in baccalaureate nursing students', Journal of Nursing Education 26,113-117. Gilligan, C: 1982, In a Different Voice, Harvard University Press, Cambridge, Mass. Gilligan, C: 1987, 'Moral orientation and moral development', in E.F. Kittay and D.T. Meyers (eds.), Women and Moral Theory, Rowman and Littlefield, Totowa, N.J., pp. 19^-33. Gortner, S.R., and Zyzanski, S.J.: 1988, 'Values in the choice of treatment: Replication and refinement', Nursing Research 37(4), 240-244. Griffin, A.P.: 1983, 'A philosophical analysis of caring in nursing', Journal of Advanced Nursing 8(4), 289-295. Hinshaw, A.S., and Atwood, J.R.: 1983, 'Nursing staff turnover, stress, and satisfaction: Models, measures, and management', in H.H. Werley and J.J. Fitzpatrick (eds.), Annual Review of Nursing Research Vol. 1, Springer Publishing Co., New York, pp. 133-153. Holmes, C.A.: 1989, 'Health care and the quality of life: A review', Journal of Advanced Nursing 14,833-S39. Huggins, E.A., and Scalzi, C.C.: 1988, 'Limitations and alternatives: Ethical practice theory in nursing', Advances in Nursing Science 10(4), 43-47. Institute of Medicine: 1982, The study of nursing and nursing education', National Academy of Science, Washington, D.C. Jacobson, S.F.: 1978, 'Stressful situations for neonatal intensive care nurses', The American Journal of Maternal Child Nursing 3, May/June, 144-150.

256

Joy Hinson Penticuff

Jennings, B.M. and Melies, A.I.: 1988, 'Nursing theory and administrative practice: Agenda for the 1990's', Advances in Nursing Science 10(3), 56-69. Katz, D., and Kahn, R.L.: 1966, The Social Psychology of Organizations, John Wiley and Sons, New York. Keane, A., Ducette,}., and Adler, D.C.: 1985, 'Stress in ICU and non-ICU nurses', Nursing Research 34(4), 231-236. Ketefian, S.: 1981a, 'Critical thinking, educational preparation, and development of moral judgment among selected groups of practicing nurses', Nursing Research 30(2), 98-103. Ketefian, S.: 1981b, 'Moral reasoning and moral behavior among selected groups of practicing nurses', Nurses Research 30(3), 171-176. Ketefian, S.: 1985, 'Professional and bureaucratic role conceptions and moral behavior among nurses', Nursing Research 34(4), 248-253. Ketefian, S.: 1987, 'A case study of theory development: Moral behavior in nursing', Advances in Nursing Science 9(2), 10-19. Ketefian, S.: 1988, Moral Reasoning and Ethical Practice in Nursing: An Integrative Review, National League for Nursing Publication #15-2250, New York. Ketefian, S.: 1989a, 'Moral reasoning and ethical practice', in Fitzpatrick, J.J., Tauton, R.L., and Benoliel, J.Q. (eds.), Annual Review of Nursing Research Volume 1 New York: Springer Publishing Co., pp. 173-195. Ketefian, S.: 1989b, 'Moral reasoning and ethical practice in nursing: Measurement issues', Nursing Clinics of North America 24(2), 509-521. King, I.: 1971, Toward a Theory for Nursing: General Concepts, Wiley, New York. Kjervik, D.K. et al.: 1988, The legal meaning of consent in unequal power relationships', Journal of Professional Nursing 4(3), 192-204. Kohlberg, L.: 1984, Essays on Moral Development: The Psychology of Moral Development, Harper and Row, New York. Kuhn, T.: 1962, The Structure of Scientific Revolutions Chicago: University of Chicago Press. Leininger, M.: 1988, Care: Discovery and Uses in Clinical and Community Nursing, Wayne State University Press, Detroit. Leonard, V.W.: 1989, 'A Heideggerian phenomenologic perspective on the concept of the person', Advances in Nursing Science 11(4), 40-55. Martin, D. and Penticuff, J.H.: 1989, 'Final Report to the American Nurses' Foundation: Psychometric Refinement of the Nursing Ethical Involvement Scales', unpublished manuscript, The University of Texas at Austin School of Nursing. Mayberry, M.A.: 1986, 'Ethical decisionmaking: A response of hospital nurses', Nursing Administration Quarterly 10(3), 75-81. Mishel, M.H. and Murdaugh, C.L.: 1987, 'Family adjustment to heart transplantation: Redesigning the dream', Nursing Research 36(6), 332-338. Munhall, P.: 1980, 'Moral reasoning levels of nursing students and faculty in a baccalaureate nursing program', Image 12(3), 57-61. Munhall, P.: 1982, 'Nursing philosophy and nursing research: In apposition or opposition?', Nursing Research 31(3), 176-181.

Conceptual Issues in Nursing Ethics Research

257

Murphy, C.C.: 1977, 'Levels of moral reasoning in a selected group of nursing practitioners', Ph.D. Dissertation, Teachers College, Columbia University. Mustapha, S.L., and Seybert, J.A.: 1989, 'Moral reasoning in college students: Implications for nursing education', Journal of Nursing Education 28(3), 107-103. Newman, M.A.: 1986, 'Nursing's theoretical revolution', in Nicholl, L.H. (ed.), Perspectives on Nursing Theory, Little, Brown and Co., Boston, pp. 72-77. Nokes, K.M.: 1989, 'Rethinking moral reasoning theory', Image 21(3), 172-175. Okin, S.M.: 1989, 'Reason and feeling in thinking about justice', Ethics 99(2), 229-249. Ornery, A.: 1989, 'Values, moral reasoning, and ethics', Nursing Clinics of North America 24(2), 499-508. Penticuff, J.H.: 1989, 'Infant suffering and nurse advocacy in neonatal intensive care', Nursing Clinics of North America 24(4), 987-997. Penticuff, J.H.: 1990a, 'Ethics in pediatric nursing: Advocacy and the child's "determining self", Issues in Comprehensive Pediatric Nursing 13(5), in press. Penticuff, J.H.: 1990b, 'Final Report: Nurses ethical decision making in perinatal settings', Unpublished manuscript, The University of Texas at Austin School of Nursing. Peterson, L.M.: 1988, 'Refusing medical treatment', Perspectives in Biology and Medicine 31(3), 454-160. Phillips, L.R. and Rempusheski, V.R.: 1986, 'Caring for the frail elderly at home: Toward a theoretical explanation of the dynamics of poor quality family caregiving', Advances in Nursing Science 8(4), 62-84. Pinch, W.J.: 1989, 'Ethical decision making for high-risk infants: The parents' perspective', Nursing Clinics of North America 24(4), 1017-1023. Prescott, P.A. and Dennis, K.E.: 1985, Tower and powerlessness in hospital nursing departments', Journal of Professional Nursing 1(6), 348-355. Rickelman, B.L.: 1971, 'Bio-psycho-social-linguistics: A conceptual approach to nurse-patient interaction', Nursing Research 20(5), 398-403. Rogers, M.E.: 1970, Introduction to the Theoretical Basis of Nursing, F.A. Davis Co., Philadelphia. Roy, C: 1984, Introduction to Nursing: An Adaptation Model, Prentice-Hall, Englewood Cliffs, NJ. Savage, T.A., Cullen, D.L., Kirchoff, K.T., et al.: 1987, 'Nurses' responses to donot-resuscitate orders in the neonatal intensive care unit', Nursing Research 36(6), 370-373. Schlaefli, A., Rest, J.J., and Thoma, S.J.: 1985, 'Does moral education improve moral judgment? A meta-analysis of intervention studies using the Defining Issues Test', Review of Educational Research 55,319-352. Shelly, S.I., Zahorchak, R.M., and Gambrill, CD.: 1987, 'Aggressiveness of nursing care for older patients and those with do-not-resuscitate orders', Nursing Research 36(3), 157-162. Silva, M.C.: 1985, 'Comprehension of information for informed consent by spouses of surgical patients', Research in Nursing and Health 8,117-124.

258

Joy Hinson Penticuff

Stevens, P.E.: 1989, 'A critical social reconceptualization of environment in nursing: Implications for methodology', Advances in Nursing Science 11(4), 56-68. Stevenson, J.S.: 1989, 'Quantitative care research: Review of content, process, product', Paper prepared for Wingspread Conference, Knowledge about Care and Caring, Racine, Wisconsin. Valentine, K.: 1989, 'Caring is more than kindness: Modeling its complexities', Journal of Nursing Administration 19(11), 28-34. Walker, L.O.: 1986, 'Toward a clearer understanding of the concept of nursing theory7, in Nicholl, L.H. (ed.), Perspectives on Nursing Theory, Little, Brown and Co., Boston, pp. 26-26. Watson, J.: 1985, Nursing: Human Science and Human Care, Appleton-CenturyCrofts, CT, Colorado Associated University Press, Boulder, CO. Watson, J.: 1988, Nursing: Human Science and Human Care, New York, National League for Nursing. White, G.B.: 1983, 'Philosophical ethics and nursing - a word of caution', in Chinn, P.L. (ed.), Advances in Nursing Theory and Development, Aspen, Rockville, MD., pp. 35-46. Wilkinson, J.M.: 1986/87, 'Moral distress in nursing practice: Experience and effecf, Nursing Forum 23(1), 16-29. Yeo, M.: 1989, 'Integration of nursing theory and nursing ethics', Advances in Nursing Science 11(3), 33-42.