Ethical Decision-Making Abilities: Reflection on
Moral Accountability
By
Dr. Eileen Watson, EdD, RN, MSN, ANP,GNP,LNC-C
Associate Professor of Nursing
CSULB, School of Nursing
1
Purposes of Module
1. To increase the student nurse’s knowledge of the distinction
between ethics and law, ethical theories and principles
2. To assess one’s moral attitudes, beliefs, and values
3. To increase the student nurse’s knowledge of current ethical
issues occurring in clinical practice settings
4. To promote the development of student nurse’ skills in ethical
decision-making, moral reasoning, moral judgment and ethical
reflection
5. To examine Professional Code of Ethics
2
Module Objectives
Upon completion of this learning module with its assigned
readings and learning activities, the student nurse will be able
to:
1. 1. Define the terms: ethics, morals, attitudes, beliefs, values,
ethical dilemma, and moral accountability
2. Discuss Kohlberg’s (1971) Theory/Stages of Moral
Development
3. Differentiate ethical theories of deontology, teleology, and
principalism
3
Module Objectives cont.
4. Apply to nursing practice eight ethical principles
5. Identify the nine provisions and the key interpretive statements for
each provision of the American Nurses Association (ANA) Code of
Ethics for Nurses With Interpretive Statements (2001) and discuss how
each provision may effect the practice of nursing
6. Identify ethical issues frequently seen in clinical settings
4
Module Objectives cont.
7. Identify symptoms of moral distress experienced by nurses
in clinical practice
8. Identify moral distress activity sources in clinical practice and
academic settings
9. Identify negative impacts in health care work environments
caused by moral distress
10. Analyze the MORAL model in ethical decision-making
11. Discuss the pros and cons of selected ethical issues such as
medical futility, foregoing nutrition and hydration, social justice,
abortion, active euthanasia, and assisted suicide
5
Module Objectives cont.
12. Identify California state laws associated with selected ethical
issues in objective #11, if applicable
13.Guided by the influence of one’s personal values,
professional codes, and patient care preferences, debate the
legal and ethical principles in the analysis of selected ethical
issues in objective #11
14. Discuss ANA’s Position on Ethics and Human Rights
6
Definition of Terms
• Ethics: branch of philosophy that examines the moral value of
human conduct. Source is internal to oneself
• Values: personal beliefs about truth, thoughts, action, or
objects
• Values Clarification; “a process aimed at understanding the
nature of one’s own value system and its vast impact on the
individual” (Guido, 2010, p. 3). Why is this important to
nursing?
• Value Systems: personal, professional, societal
• Ref. Guido, 2010, Ch.1
7
emw
7
Definition of Terms cont.
• Ethical Dilemma: when an individual must choose between
two equally unfavorable alternatives. Occurs when there is
conflict between 2 or more ethical principles and there is no
obvious “right” decision (Kelly, 2010). Jameton (1984)—Initial
dimension and reactive dimension.
Personal values and professional experiences
influence attitudes of nurses when pondering ethical
dilemmas (Winland-Brown & Dobrin, 2009)
• Ethical Reflection: Schon (1967). Reflection on Action
• Nursing Code of Ethics: Defines the profession’s values and
standards of conduct
8
Definition of Terms cont.
• Morals: are personal principles
• Morality: is one’s exhibited behavior influenced by personal
principles
• Moral Distress: occurs when a situation involves conflict
between 2 ethical principles
• Moral Reasoning: is thinking and reasoning about what one
ought to do based on ones morality
• Moral Judgment: a decision to act or not act based on what
an individual believes is good/bad—right or wrong
• Moral Accountability: Being responsible for one’s actions==
(Duty To Oneself)
Ref. Guido (2010) Ch. 1 and 2
9
Symptoms of Moral Distress
• Physical: headaches, tiredness, gastrointestinal symptoms,
shaking, pain
• Psychological: feelings of guilt, anxiety, frustration, anguish,
confusion
• Ref. Ganske (2010), p. 3
10
Moral Distress Activity Sources For Nurses,
Administration, Educators and/or Students
Clinical Practice Settings
• Nonsupportive/nonrespectful ethical climate
• Nurses core personal values
and ethical obligations
conflict
• End-of-life situations
• Protection of patient rights
• Unfair distribution of
resources
Academic Settings
•
•
•
•
•
•
•
Cheating
Plagiarism
Grade inflation
Student/Colleague incivility
Academic admission standards
Cultural issues
Standards of profession
Ref. Ganske, (2010), p. 3
11
Impact on Health Care Work Environments
Caused by Moral Distress
•
•
•
•
•
•
Nurses lose capacity for caring
Nurses withdraw from bedside
Nurses avoid patient contact
Nurses fail to give good physical care
Nurses leave the profession
Nurses feel loss of integrity and dissatisfaction
• Ref. AACN Position Paper on Moral Distress (2008)
12
Kohlberg’s Theory/Stages of Moral
Development
• Kohlberg’s theory holds that moral reasoning, which is the
basis for ethical behavior, has six identifiable developmental
stages (Psychology Wiki, 2011)
• Level One—Preconventional:
Stage 1-Obedience and punishment orientation
Stage 2-Self-interest orientation
“Reasoners in pre-conventional level judge the morality of an
action by its direct consequences” (Psychology Wiki, 2011,p. 3)
13
Kohlberg’s Theory/Stages of Moral
Development cont.
• Level Two—Conventional:
Stage 3—Interpersonal accord and conformity orientation
Stage 4—Authority and social-order maintaining orientation
“Persons who reason in a conventional way judge the morality of
actions by comparing these actions to societal views and
expectations” (Psychology Wiki, 2011, p. 3)
• Majority of American society use conventional moral
judgment(Kohlberg, 1981; Rest, Turiel, & Kohlberg, 1969;
Winland-Brown & Dobrin, 2009)
14
Kohlberg’s Theory/Stages of Moral
Development cont.
• Decasterle, Grypdonck, Vuylsteke-Wauters, & Janssen (1997)
studied 2,624 nursing students’ ethical behavior for five
different nursing dilemmas. Guided by Kohlberg’s theory,
results indicated that most nursing students are at the
conventional level of moral development that is “students are
guided by professional rules, norms and duties, and have yet
succeeded in making personal ethical decisions on the basis of
their own principles and acting according to such decisions”
(p. 12)
• Conventions and/or laws are used by nurses as their
predominant decision-making criteria in ethical dilemmas
(Carmel,et al.2007; DeCasterle, et al. 2008; Winland-Brown &
Dobrin, 2009.)
15
Kohlberg’s Theory/Stages of Moral Development
cont.
• Level Three—Postconventional: (Principled Level)
Stage 5—Social contract orientation
Stage 6—Universal ethical principle orientation
• “A person at this level attempts to clearly define universal morals in
terms of self-chosen principles. In health care, those principles
include autonomy, beneficence, nonmaleficence, justice, veracity,
fidelity, and justice. The stages of moral development are
hierarchical and attainment of each stage of moral judgment is
prerequisite to attainment of the next higher stage (Kohlberg,
1976)” (Winland-Brown & Dobrin, 2009, p. 2)
16
Kohlberg’s Theory/Stages of Moral
Development cont.
• Murphy (1976) as cite in Ketefian (1981) “….to function
optimally and independently in a complex milieu and to act as
a responsible and accountable moral agents, nurses need to
have attained a postconventional level of morality and that
conventional morality is dysfunctional. At the conventional
level of moral development the nurse would be oriented
toward maintaining institutional expectations and harmonious
interpersonal relationships. A nurse at this level is unable to
function adequately when important values compete in
individual situations or when conflicts of duty arise” (p. 102).
17
Summary of Kohlberg’s Theory/Stages of Moral
Development
• Moving from one stage to the next “rest not only on exposure
to the next level of thought, but to experiences of conflict of
the individual’s current level of thought with ethical situations
(Kohlberg & Blatt, 1973). Higher state reasoning is assimilated
only if cognitive conflict is stimulated. Moral reasoning at a
stage higher than one’s own leads to increased moral thinking
at the next higher stage, only if it disagrees with, or
introduces uncertainty into, the individual’s own decision on
moral dilemmas (Kohlberg & Blatt, 1973; Rest, Turiel, &
Kohlberg, 1969) “ (Winland-Brown & Dobrin, 2009, p. 2)
• Ethical Debates—an intervention to create
uncertainty/conflict on ethical issues
18
Ethical Theories
• Deontological: intention factor with humanism; there are
aspects of an act other than its consequences which
determine its morality (nonconsequentialist)
• Teleological: intention factor with rules and principles; the
consequences of an act are the most important factors in
determining morality (consequential, utilitarian, situational).
• Principalism: incorporates combinations of ethical principles
and attempts to resolve ethical dilemmas by applying one or
more ethical principles
• Ref. Guido, 2010, Ch. 1
19
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19
Ethical Principles: Nursing Profession
• “Reasoning using ethical principles as a guide reflects
reasoning at a principled level, the highest level in moral
development” (Winland-Brown &Dobrin, 2009, p. 2)
• 1. Autonomy—addresses personal rights of freedom and selfdetermination; the right for someone to control their health
care decision, even if someone else does not agree--**How
can this this right be taken away?
• 2. Beneficience—promoting good to others. Problem is in
defining “good.”
20
Ethical Principles: Nursing Profession cont.
• 3. Nonmaleficience—states that one should do no harm.
What about pain with procedures?
• 4. Fidelity—is keeping one’s promises or commitments.. Cite
examples?
• 5. Veracity—concerns always telling the truth. Cite how this is
done.
• Ref. Guido, 2010, Ch. 1
21
Ethical Principles: Nursing Profession cont.
• 6. Justice—all people should be treated fairly and equally.
With hospital cost containment measures does patient
equality always occur?
• 7. Respect for Others—highest principle; incorporates all
ethical principles; acknowledges the right of individuals to
make their own informed decisions-- to live or die by those
decisions
• Case Study Exercises. Guido, 2010, p. 10. Exercise 1.2 #1-4.
Identify what ethical principles you feel should be used by the
nursing staff for each case study. Class discussion exercise.
22
ANA Code of Ethics With Interpretive
Statements
9 Provisions:
Provisions 1-3: Discuss Fundamental Values of the
Professional Nurse
Provisions 4-6: Discuss Duty and Loyalty
Provisions 7-9: Discuss Expanded Duties Beyond Direct
Patient Care
23
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 1—The nurse, in all professional relationships,
practices with compassion and respect for the inherent
dignity, worth, and uniqueness of every individual,
unrestricted by considerations of social or economic status,
personal attributes, or the nature of health problems.
• 1.1 Respect for human dignity
• 1.2 Relationships to patients
• 1.3 The nature of health problems
• 1.4 The right to self-determination
• 1.5 Relationships with colleagues and others
• REF. ANA Code of Ethics with Interpretive Statements (2001)
24
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 2. The nurse’s primary commitment is to the
patient, whether an individual, family, group, or community
• 2.1 Primacy of patient’s interests
• 2.2 Conflict of interest for nurses
• 2.3 Collaboration
• 2.4 Professional boundaries
• Ref. ANA Code of Ethics with Interpretive Statements (2001)
25
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 3. The nurse promotes, advocates for, and thrives to
protect the health, safety, and rights of the patient
• 3.1 Privacy
• 3.2 Confidentiality
• 3.3 Protection of participants in research
• 3.4 Standards and review mechanisms
• 3.5 Acting on questionable practice
• 3.6 Addressing impaired practice
• Ref. ANA Code of Ethics with Interpretive Statements (2001)
26
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 4. The nurse is responsible and accountable for
individual nursing practice and determines the appropriate
delegation of tasks consistent with the nurse’s obligation to
provide optimum patient care.
• 4.1 Acceptance of accountability and responsibility
• 4.2 Accountability for nursing judgment and action
• 4.3 Responsibility for nursing judgment and action
• 4.4 Delegation of nursing activities
• Ref. ANA Code of Ethics for Nurse with Interpretive
Statements (2001)
27
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 5. The nurse owes the same duties to self as to
others, including the responsibility to preserve integrity and
safety, to maintain competence, and to continue personal and
professional growth.
• 5.1 Moral self-respect
• 5.2 Professional growth and maintenance of competence
• 5.3 Wholeness of character
• 5.4 Preservation of integrity
• Ref. ANA Code of Ethics for Nurse with Interpretive
Statements (2001)
28
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 6. The nurse participates in establishing,
maintaining, and improving health care environments and
conditions of employment conducive to the provision of
quality health care and consistent with the values of the
profession through individual and collective action.
• 6.1 Influence of the environment on moral virtues and values
• 6.2 Influence of the environment on ethical obligations
• 6.3 Responsibility for the health care environment
• Ref. ANA Code of Ethics for Nurse with Interpretive
Statements (2001)
29
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 7. The nurse participates in the advancement of the
profession through contributions to practice, education,
administration, and knowledge development.
• 7.1 Advancing the profession through active involvement in
nursing and in health care policy
• 7.2 Advancing the profession by developing, maintaining, and
implementing professional standards in clinical,
administrative, and educational practice
• 7.3 Advancing the profession through knowledge
development, dissemination, and application to practice
• Ref. ANA Code of Ethics for Nurse with Interpretive
Statements (2001)
30
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 8. The nurse collaborates with other health
professionals and public in promoting community, national,
and international efforts to meet health needs.
• 8.1 Health needs and concerns
• 8.2 Responsibilities to the public
• Ref. ANA Code of Ethics for Nurse with Interpretive
Statements (2001)
31
ANA Code of Ethics With Interpretive
Statements Cont.
• Provision 9. The profession of nursing, as represented by
associations and their members, is responsible for articulating
nursing values, for maintaining the integrity of the profession
and its practice, and for shaping social policy
• 9.1 Assertion of values
• 9.2 The profession carries out its collective responsibility
through professional associations
• 9.3 Intra-professional integrity
• 9.4 Social reform
• Ref. ANA Code of Ethics for Nurse with Interpretive
Statements (2001)
32
Examples of Professional Nursing Organizations
Guiding the Ethical Practice of Nursing
• ANA Nursing Code of Ethics With Interpretive Statements (2001)
• International Council of Nurses (ICN) (2006)
• National Student Nurses’ Association, (NSNA) Inc. Code of Ethics;
Part II. Code of Academic and Clinical Conduct and Interpretive
Statements. [Adopted by NSNA Board of Directors, Oct. 27, 2009 in
Phoenix, AZ]
“As students are involved in clinical and academic environments we
believe that ethical principles are a necessary guide to professional
development…” (NSNA, 2009, p. 1). …..“6. Actively promote the
highest level of moral and ethical principles and accept responsibility
for our actions….” (NSNA, 2009, p. 4).
Retrieved from: http://www.nsna.org/pdf/pubs_code-ac.pdf
33
NANDA Approved Nursing Diagnoses
• Domains of Nursing Diagnosis for Ethical Issues
Domain 10. Domains Life Principles
1. Values
2. Beliefs
3. Values/belief/Action Congruence
Nursing Diagnoses:
Decisional Conflict
Moral Distress
Retrieved from:
http://nandanursingdiagnosislist.com/tag/nanda-nursingdiagnosis-list
34
Legal and Ethical Comparisons
REF. Guido, G. (2010). Legal and ethical issues in nursing (5th
ed.). New Jersey: Pearson Hall.
Legal
• Concerns conduct and
actions
• Concerns all of society
• Laws enforced by courts,
statutes, and the board of
registered nursing
Ethical
• Concerns attitudes and
motives
• Concerns the individual
• Ethics guided by ethical
rounds, ethical committees,
professional organizations
35
Legal/Illegal Questions For Ethical Issues
• Before one proceeds examining ethical issues, one must ask
oneself—IS IT:
•
•
•
•
Ethical/Legal
Ethical/Illegal
Unethical/Legal
Unethical/Illegal
36
Examples of California Laws on Ethical Issues
•
•
•
•
•
Assisted Suicide: Ca. Pen. Code Statute 401
Abortion: Health & Safety §§123460 et seq., 123450
Active Euthanasia: Code Section Probate §4653
Advance Directive: Ca. Probate Code Section 4701
Do-Not-Resuscitate: orally to MD by competent patient,
surrogate,(family member if patient is terminally ill or
unconscious and no advance directive, 2 physicians if CPR
determined to be medically futile—check hospital policy on
required discussions and conditions); in writing by competent
patient in form of living will or advance directive prior to
becoming ill (Medical-Malpractice. Lawyers.com)
• Medical Futility: Ca. Probate Code Section 4735
37
Ethical Issues in Nursing Practice, Examples
•
•
•
•
•
•
•
•
•
•
•
Topics of death and dying, DNR:Do-Not-Resuscitate
End-of-life care issues
Quality versus quantity of life
Palliative care issues
Advance directives
Compromised standards
Medical futility
Withdrawal of food/fluid
Social justice/injustice
Reporting/Not reporting compromised co-workers
Religious beliefs
38
Ethical Issues in Nursing Practice Cont.
•
•
•
•
•
•
•
•
•
•
Scarcity of resources
Downsizing
Technological advancements
Genetics
Abuse: elder, child, physical, financial or emotional
Euthanasia
Assisted suicide
Abortion
Drug abuse
Organ donation, harvesting, stem-cell
39
Ethical Reflection
• Ethical decision-making involves reflection on the following
questions;
• “Who should make the choice?
• What are the possible courses of action?
• What are the available options or alternatives?
• What are the consequences, both good and bad, of all
possible options?
• Which rules, obligations, and values should direct choices?
• What are the desired goals and outcomes? (Guido, 2006, p.
8)” Ref: Guido, 2010, p. 16.
40
Moral Model
• 1. Massage the dilemma (identify involved parties and define
issues)
• 2. Outline the options (examine all + and – options, pros/cons)
• 3. Resolve the dilemma (decide best option)
• 4. Act by applying option (most difficult step)
• 5. Look back/evaluate the process
• Class Room Exercise. Exercise 2.1 in Guido, 2010, p. 17. Read
scenario and apply moral model. Identify which provisions of
the nursing code of ethics with interpretive statements (2001)
guide resolving the dilemma?
41
Ethics and Human Rights Issues
• Debate Classroom Session—Pros and Cons—ANA Position; Ethical
Principle, California Laws, if applicable.
• Foregoing Nutrition and Hydration
• Medical Futility
• Active Euthanasia, Assisted Suicide
• Social Justice
• Abortion
• Resources:
http://www.nursingworld.org/MainMenuCategories/EthicsStandard
s/Ethics-Position-Statements.aspx
and
Guido, G. (2010). Legal and ethical issues in nursing (5thed.). New
ersey: Pearson Hall.
42
Module Summary
• Moral development, reasoning, and accountability are ongoing processes.
• …professionals’ ethical practice and ethical decision making
remain a highly individualistic intuitive, and common sense
process rather than one well-reasoned and well-informed”
(Ketefian, 1981, p. 98).
• ”Nurses are faced daily with ethical dilemmas in which they
must make a decision. The decisions they will make will be
affected by so many factors including principles learned in
school and their own personal beliefs, values and
experience. Are these choices “right or wrong?”” Retrieved
from:
http://www.nursetogether.com/desktopmodules/engagepu
blish/printerfriendly.aspx?itemid=2520&portalid
43
Module Summary Cont.
• Communication is a strong variable in how nurses’ make ethical
decisions
• Nurses’ duties—oneself, professional (patients and institution), and
societal
• American Nurses’ Association Code of Ethics with Interpretive
Statements (2001)—duty to oneself—in Provision 5.
• American Association Colleges of Nursing (AACN) (2008) Developed
the Essentials for Baccalaureate Education document stating the
nursing student must learn “…to reflect on one’s own beliefs and
values as they relate to professional practice” (p. 5)
• Guido (2010) summarized duty to oneself by stating
“Understanding one’s ethics and values is the first step in
understanding the ethics and values of others and in assuring the
delivery of appropriate nursing care” (p. 4)
44
Reference List
• AACN (2008). Public Policy Position Paper on Moral Distress.
Retrieved from:
http://www.aacn.org/wd/practice/content/ethicmoral.pcms?menu=practice
• AACN (2008). 4 A’s to Rise Above Moral Distress Handbook; 4
A’s to Rise Above Moral Distress Toolkit and Bibliography.
Retrieved from:
http://www.aacn.org/wd/practice/content/ethicmoral.pcms?menu=practice
and
http://classic.aacn.org//aacn/practice.nsf/ad0ca3b3bdb4f33288
256
45
Reference List Cont.
• Aiken, T. (2004). Legal, ethical and political issues in nursing (2nd ed.).
Philadelphia: F.A. Davis
• American Nurses Association (ANA). (2001). Code of ethics for nurses with
interpretive statements. Washington, DC: American Nurses Publishing.
• Bosek, M. & Savage, T. (2007). The ethical component of nursing
education: Integrating ethics into clinical experience. Philadelphia:
Lippincott Williams & Wilkens
• Butts, J. & Rich, K. (2005). Nursing ethics across the curriculum and into
practice. Boston: Jones and Bartlett.
46
Reference List Cont.
•
•
•
•
•
•
•
Carmel, S., Werner,p., & Ziedenberg, H. (2007). Physicians’ and nurses’
preferances in using life-sustaining treatments. Nursing Ethics 14(5), 665-674
Clavreul, G. (2008). A question of nursing ethics. Retrieved from:
http://www.workingnurse.com/articles/a-question-of-nursing-ethics
Crain, W. (1985). Kohlberg’s stages of moral development. Theories of
development (19 pages). New Jersey: Prentice-Hall.
Decasterie, B., Grypdonck, M., Vuylsteke-Wauters, M., & Janssen, P. (1997).
Nursing students’ responses to ethical dilemmas in nursing practice. Nursing
Ethics 4(1), 12-28
DeCasterle, B., Izumi, S., Godfrey, N., & Denhaaerynck, K. (2008). Nurses’
responses to ethical dilemmas in nursing practice: meta-analysis. Journal of
Advanced Nursing 63 (6), 540-549
Duckett, l., Rowan, M., Ryden, M., Krichbaum, K. et al. (1997). Progress in the
moral reasoning of baccalaureate nursing student between program entry and
exit. Nursing Research 46 (4), 222-229
47
Reference List Cont.
•
•
•
•
•
Edmonson, C. (2010). Moral courage and the nurse leader. The
Online Journal of Issues in Nursing, 15(3). American Nurses
Association
Fry, S. (1985). Individual vs aggregate good: Ethical tension in
nursing practice. International Journal of Nursing Studies, 22(4),
303-310.
Frye, S. (1989). Teaching ethics in nursing curricula. Nursing Clinics
of North America, 24(2), 485-497.
Ganske, K. (2010, Sept.). Moral distress in academia. OJIN. Online
Journal of Issues in Nursing. 15(3), Manuscript 6, pp. 1-11.
Guido, G. (2010). Legal and ethical issues in nursing (5th ed.). New
Jersey: Pearson Hall.
48
Reference List Cont.
• Hirschmann, D. (1991). Moral reasoning of nurses: Care perspective
versus justice perspective. Reno, NV: University of Nevada
• Hook, K. and White, G. ( 2009, Nov.). Continuing education module
on the code of ethics for nurses with interpretive statements 2001.
Retrieved from:
http://www.nursingworld.org/mods/mod580/code.pdf
• Kelly, P. (2010). Essentials of nursing leadership and management
(2nd ed.).United States: Delmar Cengage learning
• Kerr, J.(2008). Ethics and retention. Advance for Nurses, 5(11), 22
• Keteflan, S. (1981). Critical thinking, educational preparation, and
development of moral judgment. Nursing Research 30(2), 98-103
49
Reference List Cont.
•
•
•
•
•
Kohlberg, L. (1981). Essays on moral development, Vol.1; The philosophy
of moral devilment. San Francisco: Harper and Row
Kohlberg, L. & Blatt, M. (1973). The effects of classroom moral discussion
upon children’s level of moral judgment. In Recent Research in Moral
Development. New York: Holt, Rinehart & Winston
Kohlberg, L., & Turiel, E. (1971). Moral development and moral education.
In C.M. Beck, E. Sullivan (Eds.) (pp. 415-16)Psychology and Educational
Practice, Glenview, Ill.: Scott & Foresman
Murphy, C. (1976). Levels of moral reasoning in a selected group of nurse
practitioners. New York: Teachers College, Columbia University.
(Unpublished Doctoral Dissertation)
Numminen, O. & Leino-Kilpi, H. (2007). Nursing students’ ethical decisionmaking: A review of the literature. Nurse Education Today, 27(7), 796-807
50
Reference List Cont.
• Psychology Wiki (2011). Kohlberg’s stages of moral development.
Retrieved from:
http://psychology.wikia.com/wiki/kohlberg%27s_stages_of_moral_developm
ent
• Rest, J., Turiel, E., & Kohlberg, L. (1969). Level of moral development as a
determint of preference and comprehension of moral judgment made by
others. Journal of Personality 37, 225-252
• Roell, S. (1982). Moral development levels of university education
graduate and undergraduate nursing students. Dissertation Abstracts
International 43(3A), 736-737
• Smith, M. (2009, Sept.). Donald Schon: Learning, reflection and change,
The encyclopedia of informal education. Retrieved from:
www.infed.org/thinkers/et-schon.htm
51
Reference List Cont.
• Stone, S. (2000, Nov/Dec.). The purpose of a code of ethics
and code of conduct for nursing students. . Retrieved from:
http://www.nsna.org/Portals/0/Skins/NSNA/pdf/pubs_code_
of_ethics_and_code_of_conduct.pdf
• Smith, M. (2009, Sept.). Donald Schon: Learning, reflection
and change, The encyclopedia of informal education.
Retrieved from:
www.infed.org/thinkers/et-schon.htm
• Smith, M. (2009, Sept.). Donald Schon: Learning, reflection
and change, The encyclopedia of informal education.
Retrieved from:
www.infed.org/thinkers/et-schon.htm
52
Reference List Cont.
• Ulrich, c. et al. (2007). Ethical climate, ethics stress, and the
job satisfaction of nurses and social workers in the Unites
States. Social Science & Medicine 65, 1708-1719
• Winland-Brown, J. & Dobrin, A. (2009, Mar.). A comparison of
physicians’ and nurses’ responses to selected ethical
dilemmas. (p. 1-19). Retrieved from:
www.Forumonpublicpolicy.com/spring09papers/archivespr09/wi
nland.brown.pdf
• Wirtz, E. (2007). The moral integrity development of nursing
students in two-year colleges. Montana: Montana State
University (Unpublished Doctoral Dissertation)
53
Ethical Issues Legal Websites
• Abortion: Retrieved from: http://law.findlaw.com/statelaws/abortion/california
• Advanced Directive: Retrieved from
http://ag.ca.gov/consumers/pdf/AHCDS1.pdf
• Assisted Suicide: Retrieved from:
http://www.patientsrightscouncil.org/site/assisted-suicidestate-laws
• Elder Abuse Laws: California Elder Abuse Laws
Ca Penal Code 368 PC
• Euthanasia: Retrieved from: http://law.findlaw.com/statelaws/euthanasia/california
54
Ethical Issues Legal Websites cont.
• Do-Not-Resuscitate Orders: Retrieved from: http://medicalmalpractice.lawyers.com/Do-Not-Resuscitate-Orders.html
• Medical Futility: Retrieved from:
http://law.onecle.com/california/probate/4735.html
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