Critique of Research Article Moral Problems Among Dutch Nurses: A Survey by Arie JG van der Arend - Term Paper Example

Critique of Research Methods and Statistics in the Research Article: ‘Moral Problems Among Dutch Nurses: A Survey’ by Arie JG van der Arend and Corine HM Remmers-van den Hurk. Published in Nursing Ethics 1999 6 (6) Arnold This essay will critically examine the survey and report, in order to determine whether the research methods, hypotheses and findings were appropriately utilized and if they made a valid contribution to nursing research in the fields of ethics and moral problems. Each section of the article will be looked at in the order in which it was presented, using a critical appraisal checklist to assist the process of analysis. Introduction: The opening statement clearly outlines what the survey was about, and summarised methods, results, statistical analysis and conclusions. The background and rationale for completing the survey was placed in a historical context, then related to moral issues, political and technological changes and ways that informed the debate on strengthening nurses’ position in society. This preamble was not entirely clear at first, until the point was made that “These moral aspects and their associated moral problems are inherent in nursing.” Van der Arend and van den Hurk (1999). Having reviewed the literature, van den Hurk found little empirical evidence that ethical training helped nurses in everyday practice. Even when nurses identified what was actually ethical, there was doubt that philosophical and theoretical concepts were understood or applied. Given that virtually every domain of nursing in every country, lays down ethical practice guidelines UCKK, (1996) for example, it was difficult to understand that nurses were not able to identify or perceive the connections between concept and reality, as the literature review suggested. However, the study was a way to find out exactly what were problems of a moral or ethical nature, and so had a valid purpose. Despite the standards, or ethical education, these did not appear to address the reality of what nurses faced in practice, or determine what they considered to be morally problematical; the need for empirical evidence and discovery around these issues formed the study’s hypotheses. Research Question, Methods and Procedures: The areas of apparent discrepancy prompted the researchers to look for exactly what was contained in nurses’ moral problems and seek their opinions as to the extent of the problems in practice. So the researchers’ underlying purpose might be described as moving from theoretical and descriptive ethical concepts, into looking at nurses’ reality, experiences and perceptions on what constituted a moral problem. The research question formed the crux of the matter thus: “What issues are experienced as moral problems by nurses in different settings and institutions of health care and how serious are these moral problems for them?” van der Arend and van den Hurk (1999) In order to keep closely aligned with the question, and the key concepts, and bearing in mind perceptions, experiences and verbal expressions of nurses, an explorative, empirical study was devised. A further purpose was to inform the debate on the content of educational programmes and codes and regulations for nursing. Darke, Shanks and Broadbent (1998) quoting Yin (1994) point out that: “Case studies typically combine data collection techniques such as interviews, observation, questionnaires, document and text analysis. Both qualitative data collection and analysis methods (which are concerned with words and meanings) and quantitative methods (concerned with numbers and measurement may be used.” The study contained all the elements outlined above, and accessed data over a year, using a cross sectional designed questionnaire. Because they considered that not theoretical framework was available to meet their exact needs, they developed and test their own tool. The processes involved suggested a thorough approach that would result in meaningful data, and included review of the literature, panel discussion, participation, observation and interviews, pilot study and main study. Review of the Literature: In the context of the study, reviewing existing literature was an important factor in deciding the thrust of the investigation and what should be included in the questionnaire. This section of the article gave good background to aid understanding of the differences that existed between theoretical principles and ethical philosophies, and the reality of nurses’ moral problem experiences in practice. The description quoted from Jameton (1984) helped to clarify meanings when examining the researchers’ findings. His distinctions of three levels of a moral problem; “moral uncertainty (as a result of ignorance); moral dilemma (a choice from opposite principles or activities); and moral distress (the impossibility of carrying out a right choice)” may be applied respectively to the following realities experience by nurses; mistakes being made, following instructions from families or physicians against personal beliefs, and watching physicians continuing treatment instead of letting a person die in peace. The researchers contended that “some moral problems are not recognised by nurses” van der Arend and van den Hurk (1999) nor could they always see the difference between moral and nonmoral issues. These findings, from the literature review highlighted the discrepancies and supported the purpose of the study. Panel Discussion: As mentioned, the findings provided the items for the questionnaire, which were then put to a panel of nurses, researchers and members of the supervising committee, though no numbers were given or backgrounds of the nurses involved. The differences between what constituted problems in the literature and the way nurses talked of problems, meant that the original questionnaire had to be reduced to make the contents relevant. The panel also recommended ‘intermediate action’, which had not been planned for – interviews and observations. The researches proved their commitment and flexibility by acting upon the recommendations in order to ensure the quality of their collection methods, and the effectiveness of the tool, the final questionnaire. Participation, Observations and Interviews: A criticism here might be that the numbers and backgrounds of nurses involved were not provided. However, these activities were described as “useful additional instruments” for gathering data on real situations, perceptions and what the nurses said. Over two days, observations and semi-structured twin interviews were conducted in th15 of the health care settings involved in the study (91 institutions, seven different settings) This section of the article became rather convoluted as it rushed forward to the final questionnaire, and backward to the literature review. However, making sense of the researchers’ statements, they provided a definitive conclusion that nurses do not adhere to philosophical ethical concepts and may not differentiate between moral and nonmoral problems, confirming their hypotheses after the literature review. By combining their work to date and previous research, they were able to determine that circumstances and contexts of nursing experiences became morally problematical issues. This, coupled with the empirical evidence that nurses “have difficulty in discriminating between moral and nonmoral problems, especially when the distinction…is seen from a formal ethical point of view.” van der Arend and van den Hurk (1999) informed the development and construction of the questionnaire, in order that it addressed distinctions, contexts and perceptions. Pilot Study: This section of the article provided evidence and detail of the piloting process. It also proved that those it was administered to were representative of the study population, coming from 15 health care settings. A named contact managed the process in the field, by distributing, collecting and returning the test questionnaires. This method was chosen to elicit a high response, and proved successful both in the pilot and the main study. Out of 294 nurses who were given the questionnaire, 212 returned them, with anonymity and confidentiality preserved by the use of a sealed, addressed envelope. No mention was made of explanatory letters, leaflets or thanks, but perhaps this may be implicit in the process. “The clustering of items on content was confirmed by factor analysis” van der Arend and van den Hurk, and responses and comments from the testers (qualitative information) meant that reductions, reformulations and additions were put in place for the final tool. There is little doubt that the study was conducted fairly and robustly, given the actions taken before the major survey was implemented. Main Study: Questionnaire: The first part of the questionnaire was used to elicit general information and factual data such as age, sex, religion, education, job satisfaction and frequency of problems at work. This then led into the more conceptual and personal perspectives of the respondents. They rated the seriousness of difficulties for six categories of problems at work, including moral problems, by giving them a score between 0 – 10, with 10 denoting “extremely serious problems”. These were illustrated clearly in Table 1 (p.474). Parts 2 and 3 made distinctions between moral and nonmoral problems, and using real-life situations, asked nurses if they recognised them and how often they experienced them and considered them as problems. These were scored with ‘Yes’, ‘No’, ‘Never’, ‘Sometimes’, ‘Frequently’ or ‘Always’ indicating the use of closed questions. There was an open question at the end of each section that allowed for collection of qualitative data. The random sample consisted of 91 out of 150 Dutch health care settings, ranging from teaching/academic hospitals, 27 general hospitals, to nine community care institutions. Every possible setting, seven in all, was included, and clearly identified in Table 1. All nursing staff, apart from students and those with management roles were included, as well as 35 additional care workers; 2122 questionnaires were issued and a total of 1548 responded. This was a good representative sample, regionally and nationally on which to base analysis and extract valid results. Analysis: Having extracted both qualitative and quantitative data, the researchers considered that the qualitative aspects (comments, views and remarks etc.) helped the interpretation of quantitative data. For example, not all the situations described could be applied to every setting, as comments showed, and this was truthfully reported. Though there were no quotes to put this in context or illustrate, Table 2 (p.478-479), in giving quantitative results, clarified which settings did not apply. The scales constructed for analysis were clearly specified (see p. 473) and methods used included content analysis, frequencies and means, factor analysis of the total population, and comparisons between the settings and backgrounds of nurses, so providing a variance analysis. There was no apparent data dredging, as all processes were reported honestly and adhered closely to the purpose of the study, without deviation. Results: Relevant data on the characteristics of sample respondents included age, sex, religion, education levels, years of employment and work patterns, as had been stated earlier in the questionnaire section. Both significant and relevant non-significant figures were included with clear interpretations, both in-text and Table 1. Additional points were made regarding male respondents job satisfaction and frequency of problems, but the tables did not separate male and female. However, they later showed as a minor difference. The ‘seriousness of the problems’ was mostly ‘sometimes’ (the mean score), but a significant factor, supporting the original hypotheses, was that individual scores on seriousness came out as either very high or very low overall, thus showing vital differences in perceptions, as researchers had earlier identified during planning and development stages. That problems with the organisation took precedence over moral problems also supports the hypotheses. A high number 81.7% felt that they had little power or influence in institutional organisations. This study was carried out in 1999, yet in 2005, this feeling of powerlessness was illustrated in an article in Nursing Times, entitled ‘Primary Care Nurses ‘afraid to speak out’. Nurses “felt they are being bullied into keeping quiet about planned service changes” and “I spoke to a nurse in Newcastle recently who said she is being put on a redeployment list.” O’Dowd, (NT, Vol. 101, 2005, p.5). Quite a few years later, this lends credibility to the findings, despite referring to another country, and even today, staffing levels and NHS cuts reflect this comment: “many ‘sometimes’ experienced problems because of staffing levels or facilities being insufficient to give basic care. (68.6% and 58.5% respectively)” As for “problems with colleagues”, a telling point emerged when “73.1% recognised that their colleagues did not know how to deal with criticism.” Van der Arend and van den Hurk. All results were presented in-text and clarified by the simple, easily comprehended tables. The moral problems, as additional items, appeared in-text and Table 2 and illustrated that moral problems were experienced by nurses in situations that made them feel powerless, which suggested that sometimes, personal values and beliefs were challenged and over-ridden. Being able to deliver good patient care was the most important problem area. By examination of every significant difference, the framework of subscales, and providing clear explanations, the results were presented in a way that allowed the reader to understand how problems were interrelated; the subcategories showed that how one set of problems was dealt with, influenced action to solve another. Discussion: After recapping nurses’ interpretations of problems in practice, the researchers linked these to the findings of the main study, having discovered that the biggest issues where when nurses wanted to give the best care to patients, but were powerless to do so because of external factors like government policies and institutional organisation. The role of patient advocate was felt by nurses to be undermined by the lack of power and influence given to them. Baxter, (1999 quoting Copp (1986) writing on ethical communication, stated “The health care system that is supposed to be designed to return people to health now demands that patients need some form of protection from the system itself” Copp (1986). Further, included here in support of the study findings and nurse respondents’ perceptions, Baxter (1999) went on to say: “It has been suggested that the power differential in professional work which traditionally disadvantaged nurses is a sound basis for justifying the role of advocate.” These comments lend credibility to, and bear out the study’s findings. So it might be said that nurses know, in most instances, what they should be doing, recognising that their beliefs, values and intuitions motivate them to act morally and ethically, despite not always recognising problems in those contexts, but were prevented from acting as they desired to. Every aspect was considered and commented upon, demonstrating that the purposes for the survey were valid, and provided a valuable insight, connected to the title; that “nurses did not always experience situations as morally problematic….not as often as had previously been expected….the conclusion need further interpretation.” Van der Arend and van den Hurk (1999) That interpretation was important in that it supported the hypotheses and findings from the literature review, observations and interviews, that nurses in practice did not view moral problems from a moral or ethical point of view. Most informative here, were the factors contributing to perceptions, including knowing about ethics, attitudes, learning abilities and being able to influence problem solving processes. These differences in knowledge, attitudes and perceptions, and the need to look deeper, were summed up as follows by van der Arend and van den Hurk: “An open question beyond the study…is still how to interpret and deal with the moral problems that are identified as such from a (classic) formal moral point of view, but not experienced as problematical on a subjective personal level.” Bearing that comment in mind, it can be seen that Seedhouse (2000) considered that the ethics of care must not be based on the many nursing theories that exists, but discussed: “how nursing might combine tenderness with intelligent analysis – and so lead the way in ethical analysis on health care.” He produced an ethical grid that could fit with the study findings and go some way to addressing the open questions in the research. Seedhouse’s views would seem to support the researchers’ recommendations regarding training and developing the right competencies, skills and attitudes when delivering vocational nursing education in the Netherlands. This leads into the recommendations that were considered necessary to improve the moral problem situation and address the issues identified. They included, alongside education, as mentioned above, input by nurses into moral management policies, courses in ethics and the need for further research. The purpose of further research would be to confirm the validity of results, look at important issues in depth and compare results from different cultural backgrounds. The findings, results, analysis and discussion, because of the thoroughness of processes, comparisons made and collection of empirical evidence, successfully linked the study to the field of knowledge. The validity of the recommendations stands the test of time, for if looked at in the historical context of 1999 to the present day, it can be recognised that many have been put in place in nurse education and professional practice. Again in Nursing Times, (Vol. 101, 2005, pp.16-18), changes were shown in an article looking at 100 years of nursing practice. A timeline showed health care reforms were implemented via the NHS Plan, and “nursing employers inspected for staff-friendly policies under Improving Working Lives and Investors in People”, all of which suggested that the researchers hypotheses and recommendations were almost prophetic. Other elements of continual professional development now common to nursing practice, include reflective practice, mentoring and peer review, to name but a few. As one commentator quoted in the article said, in relation to advances in education: “The modern approach to training has helped nurses to develop a stronger professional identity…and they develop critical thinking skills, so they question what they do and why, and they question other people’s practices.” Naish, (NT, 2005, p. 18)m That sums up many of the issues identified by the researchers in the Dutch study and supports their recommendations positively. Summary of Critical Review of the Research Study: Overall, this research was conducted in a robust and methodical manner. The subjects of moral problems, ethics, and real life practice were worthy of investigation, especially in the historical context of the effects of technological medical advances, institutional organisation, hierarchical management and government policies and how these impacted on the nursing profession as a whole, and on individuals in every day situations. The researchers utilised a variety of processes to ensure that data collection methods were suitable and relevant to areas under investigation. They demonstrated flexibility in their approach, by using every research instrument considered viable as the best process to extract, analyse and interpret data as thoroughly as possible. Because they considered no theoretical framework or instruments existed that exactly matched the research needs, they went on to develop their own, and to test it appropriately. However, some criticisms may be levelled at the questionnaire process, as there is no indication whether any introductory letter, instructions or explanations were provided with the document for either the pilot sample or the main study. An example of the layout and format of the document might have been usefully included in the report. The reader must assume that the named contacts in each health care setting took responsibility for passing on the relevant information that specified the processes, purposes and requirements for such an important survey tool. But given how thoroughly and carefully the researchers approached the work, it may be inferred that the questionnaire was accompanied by the relevant information regarding completion and return; this is borne out by the high number of respondents. Analysis was clear and complete and all variables and significant differences were explained fully in-text and with tables. The tables were easy to understand and interpret. Given the size, contexts and hypotheses the researchers’ were working with, a questionnaire in the main study seemed to be the best instrument to use for gathering both qualitative and quantitative data. There was no evidence to suggest that researchers deviated from the original purpose, and this contention was proved by the honesty with which the results were presented. The results themselves included all relevant findings. The Discussion explained and interpreted all aspects of the study in a clear and comprehensible manner, for the most part, that allowed the reader to make sense of the findings. The researchers did not emphasise only the negative areas, other than how these related to and derived from the earlier stages of the process (literature review, panel, participation observation, interviews and pilot study). The pointed out that a large majority of nurses were very satisfied with their jobs, thus contradicting the views found in the literature about burn out, low standing and moral problems for nurses. There were no attempts to weight or add bias to the findings, rather they sought to present everything in a fair and honest manner that put it all into perspective. The researchers were honest in expressing the fact that not all answers were found and that some questions remained open. These are what informed the recommendations. By carrying out a literature review, and looking at other research, they placed this study into the wider field of knowledge, while relating it to the reality of nursing experience, comparing what was believed with what reality proved. They sought empirical evidence and proved it successfully, and tried to identify ways to address the issues of moral problems in the nursing role. What they discovered, and the methods employed, supported the belief that the investigation was a valid and valuable contribution to the development of education, understanding and better recognition of moral problems and formal ethics. In the final analysis, they reinforced the belief that nurses, while not always able to perceive what constituted an ethical problem, had an underlying ethos of delivering care to the very best of their abilities, if only they were allowed to do so. It seemed that nurses, despite any problems perceived or real, held onto the caring, vocational principles that brought them to the nursing role in the first place. In conclusion, placing this study in its historical context, and looking now at the education, development and ethical codes and standards within the nursing role, RCN (2005), there can be little doubt that the work carried out in this research made a valuable contribution, using the best methods and design. Reference List Academic Services Millbrook House n.d. Critically Reviewing the Literature. [Internet] Available from: http://www2.plymouth.ac.uk/millbrook/rsources/sealit/critical.htm [cited 23 April 2007] Baxter, R. 1999 Secrets and Lies: Ethical Communication. In Ann Long Ed. Interaction for Practice in Community Nursing. Basingstoke. Macmillan Press Ltd. Pp. 169-189 Bower, D., House, A. and Owens, D. 2001. Understanding Clinical Papers. Chichester. Wiley. Darke, P., Shanks, G. and Broadbent, M. 1998. Successfully Completing case study esearch: Combining rigour, relevance and pragmatism. Information Systems Journal 8 pp. 273-289 Hittleman, D. R. and Simon, A. J. 2002. Interpreting Educational Research: An Introduction for Consumers of Research. 3rd Ed. Upper Saddle River, N.J. Merrill O’Dowd, A. 2005 Primary Care Nurses ‘afraid to speak out’ Nursing Times Incorporating Professional Nurse Vol. 101 (41) p. 5. Royal College of Nursing 2005 Competencies in Nursing: Royal College of Nursing: The Role of the Nurse Practitioner. pp.8-13 [website] Available from: rcn.org.uk [cited 23 April 2007] Seedhouse, D. 2000 Practical Nursing Philosophy: The Universal Code. Chichester: Wiley Smy, J. 2005 A Century of Care. Nursing Times Incorporating Professional Nurse Vol. 101 (41) pp. 16-18 UCKK. 1996. Guidelines for Professional Practice. London: United Kingdom Council for Nursing, Midwifery and Health Visiting. Van der Arend, A., JG and Remmers-van den Hurk, C. HM, 1999 Moral Problems Among Dutch Nurses: A Survey. Nursing Ethics 6 (6) pp. 468-482 Read More