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Morality in perioperative nurses

AORN Journal, March, 2002 by Aileen R. Killen

The moral foundation of the nursing profession is based on the perspectives of Florence Nightingale, who described nursing as a self-defining moral practice focused on caring. (1) This moral foundation evolves from the nurse-patient relationship. Morality in nursing practice arises from the idea that it is morally good to promote the physical and psychological well-being of patients. (2) Nurses, however, may find it difficult to prioritize these moral nursing values over their personal values.

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In the role of moral agent, perioperative nurses accept responsibility and accountability for safeguarding the rights of patients undergoing surgical or other invasive procedures. The role of moral agent has a direct effect on the patient care experience. (3) If a patient's welfare is in jeopardy, perioperative nurses are compelled to act as moral agents. In the role of patient advocate, perioperative nurses identify patient risks and act to prevent or resolve moral dilemmas.

Limited information exists to fully describe the experience of acting morally as a professional nurse. To date, philosophy, psychology, religion, and other influences have been relied on to explain the moral actions of nurses. It has been suggested that the basis for ethics in nursing is the intersection of developmental psychology, moral philosophy, and nursing science; (4) however, inadequate evidence exists to support this argument. The basis for moral action by nurses, therefore, continues to be a poorly understood phenomenon.

RELATED LITERATURE AND THEORETICAL FRAMEWORK

Moral behavior is an exceedingly complex phenomenon. It reflects the social fabric of people living in groups whose actions affect each other. No single variable is comprehensive enough to sufficiently represent the psychology of morality. (5) Discussions of morality commonly are divided into thoughts, behaviors, and emotions. The Four Component Model of Morality developed by cognitive psychologist James R. Rest addresses the complex and diverse cognitive processes involved in moral behavior. (6) This model examines processes involved in moral behavior, including

* interpreting the situation (ie, moral sensitivity),

* determining the ideal moral course of action (ie, moral judgment),

* selecting among valued outcomes with the intention of following the moral course of action (ie, moral motivation), and

* having sufficient perseverance and implementation skills to follow through on the chosen course of action (ie, moral character).

Moral judgment. Although all four components have been theorized, the majority of research regarding the model has focused on moral judgment. Contextual variables such as gender, age, and education have been studied as predictors of moral judgment. Formal education is the best predictor of moral judgment as measured by the Defining Issues Test (DIT). (7) Although at every education level females score slightly higher than males on the DIT, education level is 250 times more powerful in predicting moral judgment scores than gender.

Moral sensitivity. Similar studies regarding moral sensitivity mirror the results of the moral judgment research. Higher moral sensitivity has been noted in professionals who have completed some level of post-basic education, and professional women have displayed a slight edge in recognizing the ethical components of a situation. (8) Limited research exists, however, regarding moral motivation and moral character.

A Model of Morality for Perioperative Nurses (MMPN) derived from the Four Component Model of Morality provided the theoretical framework for this study. The foci of investigation included two components from Rest's model--moral motivation and moral character--as well as moral action (ie, behavior) and patient and perioperative nurse outcomes.

The MMPN was formulated on the premise that moral motivation and moral character relate directly to moral action in nursing practice and, thus, relate directly to patient outcomes. Characteristics of nurses and the institution where they work affect the relationship between moral motivation, moral character, moral action, and nurse outcomes.

Moral motivation. Moral motivation requires a person to prioritize moral action over conflicting values. Moral values are not the only values a person has, thus moral motivation focuses on processes by which a person places a moral value above other values. Moral motivation involves many connections between cognition and effect. Altruism, shame, fear, guilt, and empathy may be additional motivating factors behind the selection of a moral value. (9)

Moral character. Moral character identifies the skills and perseverance required to follow through on the intention to do the moral thing. This includes the ability to work around impediments and unexpected difficulties. Rest suggests that although psychological toughness and strong character do not guarantee adequacy in the other three components of his model, these character traits are necessary to carry out a moral action. (10)

Health Care Industry

Morality in perioperative nurses

AORN Journal, March, 2002 by Aileen R. Killen

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