Ethical Issues in Nursing


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Falcó-Pegueroles et al. BMC Medical Ethics 2013, 14:22
Open Access
Development process and initial validation of the
Ethical Conflict in Nursing Questionnaire-Critical
Care Version
Anna Falcó-Pegueroles1*, Teresa Lluch-Canut2 and Joan Guàrdia-Olmos3
Background: Ethical conflicts are arising as a result of the growing complexity of clinical care, coupled with
technological advances. Most studies that have developed instruments for measuring ethical conflict base their
measures on the variables ‘frequency’ and ‘degree of conflict’. In our view, however, these variables are insufficient
for explaining the root of ethical conflicts. Consequently, the present study formulates a conceptual model that also
includes the variable ‘exposure to conflict’, as well as considering six ‘types of ethical conflict’. An instrument was
then designed to measure the ethical conflicts experienced by nurses who work with critical care patients. The
paper describes the development process and validation of this instrument, the Ethical Conflict in Nursing
Questionnaire Critical Care Version (ECNQ-CCV).
Methods: The sample comprised 205 nursing professionals from the critical care units of two hospitals in Barcelona
(Spain). The ECNQ-CCV presents 19 nursing scenarios with the potential to produce ethical conflict in the critical
care setting. Exposure to ethical conflict was assessed by means of the Index of Exposure to Ethical Conflict (IEEC), a
specific index developed to provide a reference value for each respondent by combining the intensity and
frequency of occurrence of each scenario featured in the ECNQ-CCV. Following content validity, construct validity
was assessed by means of Exploratory Factor Analysis (EFA), while Cronbach’s alpha was used to evaluate the
instrument’s reliability. All analyses were performed using the statistical software PASW v19.
Results: Cronbach’s alpha for the ECNQ-CCV as a whole was 0.882, which is higher than the values reported for
certain other related instruments. The EFA suggested a unidimensional structure, with one component accounting
for 33.41% of the explained variance.
Conclusions: The ECNQ-CCV is shown to a valid and reliable instrument for use in critical care units. Its structure is
such that the four variables on which our model of ethical conflict is based may be studied separately or in
combination. The critical care nurses in this sample present moderate levels of exposure to ethical conflict. This
study represents the first evaluation of the ECNQ-CCV.
Ethical conflicts have been analysed for several years in
various clinical contexts. Research suggests that such
conflicts are on the rise in the nursing field, due both to
the increasing complexity of care and the scientific and
technological advances which have been made in recent
decades. In this regard, critical care units are a setting that
* Correspondence:
Department of Fundamental Care and Medical-Surgical Nursing, Campus of
Health Science of Bellvitge, Nursing School, University of Barcelona, Central
Pavilion, 3r floor, 08907 L’Hospitalet de Llobregat, Barcelona, Spain
Full list of author information is available at the end of the article
is especially prone to conflict [1-14]. Various authors have
suggested that the ethical conflicts experienced by critical
care nurses stem from three main sources: the relationships
with patients and their families, the provision of certain
treatments and/or the characteristics of the setting in which
the clinical team works. As regards the first of these, the
decision-making process comes up against issues such as
the difficulty of ensuring informed consent, a failure to
respect confidentiality or the lack of protection of the
patient’s interests [5,9,15-21]. With respect to the provision
of certain treatments, nurses may experience conflict when
asked to administer treatment they regard as overly
© 2013 Falcó-Pegueroles et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Falcó-Pegueroles et al. BMC Medical Ethics 2013, 14:22
context of moral distress. Similarly, Glasberg’s construct
stress of conscience [34,35] was described as the product
of these two variables. In our view, however, the sole use
of these two variables (i.e. frequency and degree of
ethical conflict) to analyse ethical conflicts is insufficient
when it comes to explaining the root of the conflict or
the difficulty of making the correct decision from a
moral perspective. Indeed, it is noteworthy that research
has yet to consider as a whole the different types of
ethical conflict described by Jameton [27] and Wilkinson
[15]. Neither have we found any studies that take into
account the absence of moral conflict as a positive
perspective inside a model. Consequently, we have
formulated a model for the analysis of ethical conflict
(Figure 1) that is based on the following premises: a) in
order to study ethical conflict it is necessary to consider
four variables: frequency of conflict, degree of conflict,
exposure to conflict and type of conflict; b) the variable
‘exposure to conflict’ is the product of the variables
‘frequency’ and ‘degree of conflict’; c) the variable ‘type
of conflict’ should take into account the continuum
between the presence and absence of ethical conflict.
The presence of ethical conflict would correspond to the
four categories or types of conflict described by Jameton
[26,27] and Wilkinson [15]: moral uncertainty, moral
dilemma, moral distress and moral outrage. In order to
-Index of exposure to ethical conflict +
( IEEC = Fx D)
Presence of ethical
Moral outrage
Absence of ethical
aggressive, when pain management seems to be deficient or
when it becomes necessary to limit the use of life support
procedures [1,5,15-17,22-24]. Finally, in relation to
workplace dynamics, conflict may arise if nurses are not
fully involved in the decision-making process or if they
feel the work environment makes it difficult to consider
questions of a bioethical nature [4,12,15,17,19-25]. Such
situations have the potential to produce different ethical
conflicts in the individual, and these conflicts will reflect
the root of the difficulty in making the right decision. In
this context, Andrew Jameton [26] coined the term moral
distress and identified three types of ethical conflict which
nurses may experience in the clinical setting: moral
uncertainty, moral dilemma and moral distress. In a
situation of moral uncertainty the professional is either
unsure whether there is an ethical problem or not, or
recognizes that there is such a problem but is unclear
about the ethical principles involved. Moral dilemmas
arise when the professional must choose between two or
more morally correct principles, each of which would lead
to a distinct course of action. Finally, moral distress is felt
when the professional recognizes the ethical principles
involved and knows the right thing to do but is
constrained by something or somebody from acting
accordingly. Some years after Jameton’s work was first
published Judith Wilkinson [15] referred to what she
called moral outrage, a type of ethical conflict in which the
professional experiences a sense of impotence in the face of
an immoral action performed by others. In 1993 Jameton
included this type of conflict in his own classification [27].
Although a considerable body of research has considered
the types of ethical conflict experienced by nurses, only a
few studies have developed instruments for measuring
these conflicts. The principal instruments to date have
focused on the evaluation of moral distress and stress of
conscience. The Moral Distress Scale, developed by Corley
[1], was the first instrument of its kind and was subsequently adapted by various authors [6,10,11,20,21,28-30].
Kälvemark-Sporrong’s Moral Distress Questionnaire [31]
was designed to explore the relationship between moral
distress, ethical competence and the ability to tolerate stress
among health professionals. This instrument was also
adapted in subsequent research [25,31-33]. Finally, the
Stress of Conscience Questionnaire was developed by
Glasberg [34] to examine the relationship between stress of
conscience and burnout, a relationship that was later
confirmed by other studies [35-37].
Most of the research which has set out to analyse
ethical conflicts has focused predominantly on two
variables: the frequency with which situations of conflict
arise and the degree of ethical conflict perceived by the
individual concerned. As regards the relationship
between these two variables, Corley [23] and Pauly [29]
report there to be a positive relationship (p < 0.01) in the Page 2 of 8 Moral distress Moral dilemma Moral uncertainty Moral wellbeing Moral indifference Figure 1 Model for the analysis of ethical conflict. Falcó-Pegueroles et al. BMC Medical Ethics 2013, 14:22 capture the absence of ethical conflict our model defines a further two categories: moral wellbeing and moral indifference [24]. Moral wellbeing refers to a positive
state in which moral thought and action are clearly
coherent with one another. Moral indifference describes
the stance of an individual who neither shows interest in
nor takes a position on a matter of ethical concern.
Based on this model of ethical conflict we then developed
an instrument for evaluating its components. The focus of
the present study is on critical care nursing, and the paper
describes the development and validation of the instrument
designed to measure ethical conflicts in this setting, the
Ethical Conflict in Nursing Questionnaire-Critical Care
Version (ECNQ-CCV).
Item generation
The initial pool of items was created through an extensive
review of the literature on sources of ethical conflict in
nursing and in the critical care setting. During the search
particular emphasis was placed on identifying and selecting
care scenarios that generated an ethical problem, a moral
dilemma or moral distress. A total of 31 situations involving
an ethical conflict were identified. Those situations which
produced conflict of another kind, for example, staff-related
or financial, were excluded.
The 31 scenarios were then analysed and adapted to
the specific context of critical care units, grouping them
into 11 areas with the potential to produce an ethical
conflict. These areas were as follows: informed consent,
confidentiality, withholding and withdrawing treatments,
the patient’s interests, characteristics of an ethical environment, procedures and treatments, interprofessional
relationships, moral agency and professional values, privacy,
research tasks and resource management. In order to
reduce the number of scenarios we then grouped together
any that were related to one another, the result being a total
of 19 situations, each of which was represented by one item
on the questionnaire. The 19 scenarios were then analysed
in accordance with the Code of Ethics of the International
Council of Nurses [38] in order to identify which articles of
the Code might be implicated in each case.
The questionnaire: content validity and pilot study
The instrument, which we called the Ethical Conflict in
Nursing Questionnaire-Critical Care Version (ECNQCCV), was developed in Spanish and initially comprised
the 19 care scenarios with the potential to produce an
ethical conflict in nurses working in critical care units.
In order to test the content validity of this initial
version of the ECNQ-CCV each of its items was rated by
two committees of experts. One committee (the Ethics
Committee) comprised four experts in the field of ethics
and nursing ethics, while the other was formed by
Page 3 of 8
four experts in critical care nursing (the Critical Care
Committee). Each member of both committees evaluated
the ECNQ-CCV according to the following two parameters:
‘Relevance of the item for exploring ethical conflict’ (RI)
and ‘Degree of ethical conflict’ (DEC). The members of the
Ethics Committee also evaluated the items according to the
degree of agreement in the ‘Definition of ethical concepts’
(DEFEC), whereas the Critical Care Committee was asked
to consider, as a third parameter, the ‘Frequency of occurrence of each scenario’ (FO). Ratings of the four parameters
(RI, DEC, DEFEC and FO) were made using a Likert scale
with five or six response options, and there was also a
section in which the experts could make any comments or
suggestions they felt were necessary.
Content validity was then assessed by means of two
procedures. The data corresponding to the parameters RI,
DEC and FO were analysed according to the consensus
method described by Fehring [39]. This method classifies
the degree of agreement into four categories: 0 to
0.24 = no consensus, 0.25 to 0.49 = little consensus,
0.50 to 0.74 = considerable consensus, and 0.75 or
higher = strong consensus. The results showed that
three items (Item 2, Item 13 and Item 16) yielded
values below 0.50 with respect to RI and DEC,
thereby suggesting that they should be eliminated.
However, one of these items (Item 2) produced a
value above 0.50 on FO and it was therefore retained.
The other two items were replaced with two new items
suggested by some of the experts. One item referred to
the effect of a lack of resources on care, while the other
concerned institutional interests coming before those of
the patient.
The parameter DEFEC was analysed by using
Kendall’s coefficient of concordance to determine the
degree of agreement between experts. The degree of
agreement obtained was sufficient: W = 0.519 for the
four types of ethical conflict and W = 0.750 for the degree
of agreement between the categories moral dilemma and
moral distress.
The questionnaire therefore comprised 19 items, each
of which described a critical care scenario in which
nurses might experience an ethical conflict. For each
item, three questions were formulated, corresponding to
the parameters ‘frequency of occurrence of the ethical
conflict’ , ‘degree of perceived ethical conflict’ and ‘type
of ethical conflict experienced’ (Additional file 1). The
variable ‘frequency of occurrence’ was rated according to
six categories: never, almost never, at least once a year, at
least once every six months, at least once a month, and at
least once a week. ‘Degree of conflict’ was rated across five
categories: no problem at all, mildly problematic,
fairly problematic, considerably problematic, and highly
problematic. Finally, six categories were used to rate the
‘type of ethical conflict experienced’. Four of these were
Falcó-Pegueroles et al. BMC Medical Ethics 2013, 14:22
the four types of ethical conflict defined by Jameton
[26,27] and Wilkinson [15]: moral uncertainty, moral
dilemma, moral distress and moral outrage. The
remaining two categories referred to moral states in
which no ethical conflict was present: moral wellbeing
and moral indifference [24].
The instrument in this form was then piloted with a
sample of 20 nurses from the critical care unit of a
hospital in the city of Barcelona, the characteristics of
which were similar to those of the two hospitals
chosen for the main study. In this pilot study, 72% of
the nurses surveyed considered that the ECNQ-CCV
had sufficient scope and 28% regarded it as acceptable.
78% affirmed it was sufficiently clear and the remaining
22% declared it was clear. These results meant that no
substantial changes needed to be made to the design or
content of the questionnaire.
Index of Exposure to Ethical Conflict (IEEC)
As mentioned earlier the model of ethical conflict on
which this study is based includes the variable ‘exposure
to conflict’. This variable results from the relationship
between the frequency with which an individual encounters
an ethical conflict and the degree of conflict that such
situations produce in that individual. This relationship is
best regarded as a continuum. At one extreme there would
be no ethical conflict: the individual has either never been
in a situation of potential conflict, or has been but no
conflict was produced (zero frequency – zero intensity).
The other end of the continuum would be anchored
by maximum or strong ethical conflict: the individual
frequently encounters situations of ethical conflict
and the degree of conflict produced is very intense
(high frequency – high intensity). Between these two
extremes would lie intermediate combinations: low
frequency – high intensity; high intensity – low frequency.
In order to estimate ‘exposure to ethical conflict’ we
developed a specific index, the Index of Exposure to
Ethical Conflict (IEEC), which yields a reference value
for each subject. The IEEC is calculated by means of
the following equation:
ðF i D i Þ
where (Fi) is the frequency of occurrence of each
situation (Itemi) and (Di) is the degree of intensity
corresponding to that situation. The value of the
IEEC therefore provides an estimate of the frequency
and intensity with which a given subject experiences
each of the 19 scenarios listed within the ECNQCCV, the sum of its products reflecting the interaction between the ratings given for frequency and
intensity. Thus, the IEEC enables respondents to be
Page 4 of 8
evaluated and ordered according to the degree of ethical
conflict they experience. The possible score for each item
ranges from 0 to 25: 0 is the product of the categories
Zero Frequency – Zero Intensity (‘0 – Never’ × ‘0 – No
problem at all’) and 25 is the product of the categories
High Frequency – High Intensity (‘5 – At least once a
week’ × ‘5 – Highly problematic’). The range of the IEEC
is therefore 0 to 475, the upper limit being the product of
19 × 25 (19 = the number of scenarios included in the
ECNQ-CCV with the potential to produce ethical conflict
× 25 = maximum value of the IEEC for each situation).
Participants and setting
Participants were critical care nurses with at least one
year of professional experience who were recruited
through two tertiary level hospitals, one in Barcelona
(Spain) and the other in the metropolitan area of the
same city. Both centres were linked to the University of
Barcelona. The sample comprised 205 nurses who worked
in the critical care units of these two hospitals. As the total
number of critical care nurses at these hospitals was 292,
the sample accounted for 70% of the population.
Socio-demographic, academic, professional and institutional information regarding the sample was collected by
means of a data sheet comprising 20 questions. This data
sheet was attached to the ECNQ-CCV.
Administration of both the ECNQ-CCV and the
complementary data sheet took place during October
and November 2009.
Statistical analysis
All data were analysed using PASW v19 for Windows.
The tests of normality and the analyses of the reliability
and construct validity of the Ethical Conflict Nursing
Questionnaire were based on the IEEC. Internal consistency was calculated using Cronbach’s α coefficient.
Construct validity was assessed by means of Exploratory
Factor Analysis (EFA), examining the scree plot in order
to interpret dimensionality. Measures of central tendency
were studied for the IEEC, and the Kolmogorov-Smirnov
and Shapiro Wilks tests were applied in order to assess
the goodness of fit of the distributions. Variances were
also analyzed with ANOVA test or the corresponding
non- …
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