From the article below, answer the Essay prompt. You will need to download the full article.Park, M. (2009). Ethical issues in nursing practice. Journal of Nursing Law, 13(3), 68-77. doi:10.1891/1073-

Keywords:

ethical issues; nursing practice; education; hospitals A dvances in medical technology allow for bet- ter recovery for critically ill patients and dramatically extend the human life span.

However, while advances bring benefits to patients and families, they simultaneously raise moral and ethical issues regarding respect for patient integrity and autonomy, soaring medical costs, quality care, and end-of-life decision making (Scanlon & Fleming, 1990; Wright, Cohen, & Caroselli, 1997). As the largest group of health care providers, nurses are frequently placed in unique positions to assist patients and families struggling with complex information and dif- ficult decisions (Briggs & Colvin, 2002). The fact that nurses encounter clinical situations that require ethi- cal judgment highlights the need for nursing staff to gain knowledge and expertise in delivering care in an ethical manner.

Reporting the lack of ethical confidence among newly graduated nurses, nursing ethics researchers have emphasizes the importance of having well- educated and well-qualified nurses who know how to find feasible solutions to ethical problems (Bunch, 2001; Woods, 2005). Although nursing schools have become more concerned with the ethical development of their students, researchers point out that education has not reflected reality and does not prepare newly qualifying nurses to deal effectively with a variety of ethical situations in the health care setting ( Woods, 2005). The traditional ethics education has tended to emphasize the acquisition of philosophical and theoretical knowledge and has created a gap between theory and practice ( Woods, 2005). New approaches are needed for teaching nursing ethics pragmatically.

The nursing ethic as a dynamic standard for nurses’ professional moral behavior should address ethical issues confronted by nurses (Omery, Henneman, Bil- let, Luna-Raines, & Brown-Saltzman, 1995). Therefore, knowledge about specific nursing ethical issues found in the health care setting and understanding the impact of these issues on practice will be essential, pragmatic parts of nursing ethics education. That is, the ethical issues are subjects that should be dealt with in ethics education for nursing students before entering in nurs- ing practice. Thus, identifying what issues should be dealt with in classes is needed.

Researchers have tried to identify ethical issues that nurses confront in the clinical area since Vaughan’s (1935) study. The earliest study of ethical issues in nursing practice (Vaughan, 1935) identified 2,265 ethical issues based on the diaries of 95 nurses that recorded ethical issues. Since this study, many other studies have been focused on ethical issues that affect the profession of nursing and the everyday practice of individual nurses using qualitative methodolo- gies. In a review study, Christensen (2002) identified the ethical and legal issues that oncology nurses in hospitals face: (a) advance directives, ( b) do-not- resuscitate orders, (c) documentation and patient privacy, (d) informed consent, (e) medication errors, and (f ) pain management. A systematic analysis Park Ethical Issues in Nursing Practice 69 study of nurses’ ethical conflicts identified each main ethical issue in a particular role or setting (Redman & Fry, 2000). Examples were (a) harm/good of life- prolonging aggressive therapies (intensive care unit); ( b) inadequacy of resources for care (administration); (c) undertreatment, consent, and refusal of treatment (oncology); (d) disagreement with quality of medical care (diabetes educators); and (e) protection of child’s rights (pediatric nurse practitioner). However, a sys- tematic review of ethical issues encountered by nurses in current practice is rarely found.

The purpose of this study is to review the empiri- cal studies of hospital-based nurses’ experiences with ethical issues to identify (a) the ethical issues nurses face and ( b) the approaches they have taken to solving them.

METHODS This article reviewed quantitative studies of hospital- based nurses’ experiences with ethical issues. To be included in this review, a publication was to have reported the findings from a research project studying nurses’ experiences. The integrative review included the reports of primary research studies that were pub- lished in the English language from 1990 and 2007. This study began with a search of multiple library databases, including PubMed (MEDLINE), the Cumulative Index to Nursing and Allied Health (CINAHL), and ISI Web of Knowledge, to identify research related to ethical issues that nurses face. Key words used in the search process were “nursing ethics” and “issue” and/or “problem.” Additional literature was identified by reviewing the reference lists of journal articles identified during the literature review.

Examination of the published abstracts and studies resulted in a decrease of the number of studies included in the first sampling because studies that did not match the project criteria were excluded ( n = 25). This study was limited to hospital-based research and settings in the United States. Most studies in special clinic areas dealt with a more specific ethical issue or conflict situa- tion. Therefore, these articles were excluded. However, this review included the studies done in operating room areas and collected data from registered nurses in a local area because the studies dealt with more general ethical issues encountered by perioperative nurses or registered nurses with a large sample size. One article that collected data from directors of nursing in hos- pitals was included because the directors explained ethical issues not that they faced but that were faced by staff nurses. Therefore, through the second review, the researcher excluded the articles that did not match the purpose of this project.

This review classified the ethical issues reported by each study into three categories of the Ethical Issues Scale (EIS): end-of-life treatment decisions, patient care issues, and human rights issues. Fry and Damrosch (1994) developed the EIS in a study of Maryland nurses.

The EIS was validated with a sample of New England registered nurses currently in practice (Fry & Duffy, 2001). The scale described the full range of ethical issues experienced by nurses in current practice. The 32-item scale represented three conceptual categories of ethical issues: end-of-life treatments, patient care, and human rights (Fry & Duffy, 2001) (see Table 1).

The end-of-life treatment category was defined as issues about death or the dying process and included 13 issues. The patient care category addressed issues about how patients receive or do not receive quality nursing or health care (14 items). The human rights category was defined as issues concerning the rights of nurse, patients, and family members (five items). The EIS pro- vides information about the full range of ethical issues of registered nurses in active practice experience. The reliability and validity of the EIS have been validated through a study with a large RN sample ( n = 2,090) and nurses with expertise in bioethics (Fry & Duffy, 2001). RESULTS Twenty-five studies were identified through the first review process, and 11 studies met the inclusion crite- ria. All studies used a descriptive research method with survey instruments. Articles reviewed were classified into two settings: hospital and operating room. One article collected data from registered nurses in Mary- land; this article was integrated to hospital setting data.

The ethical issues reported in reviewed studies were divided into three categories (end-of-life treatment decisions, patient care issues, and human rights issues) in the EIS. This review described disturbing ethical issues that were encountered by nurses separated from the frequent ethical issues. This study identified the top five frequent ethical issues and disturbing ethical issues reported in each article and then integrated and analyzed these issues. Furthermore, this study identi- fied the approaches that nurses have taken to solve the ethical issues and the resources that nurses frequently used to get help and information.

Ethical Issues As shown in Table 2, the most of frequent ethical issues faced by nurses related to patient care issues and human 70 Journal of Nursing Law Vol. 13, No. 3 TABLE 1. The Ethical Issues Scale Component 1: End-of-life treatment decisions Prolong dying process with inappropriate measures Treatment or nontreatment despite patient or family wishes Use or removal of life support including nutrition and hydration To resuscitate or not to resuscitate Treatment or nontreatment of very disabled infant, child, adult Not considering quality of patient’s life Acting against your own personal or religious views Acting against patient’s personal or religious values Determining when death occurs Organ transplantation, or organ or tissue procurement Over- or underuse of pain management Ordering too many or too few procedures, tests, etc.

Participation or refusal to participate in euthanasia or assisted suicide Component 2: Patient care issues Staffing patterns that limit patient access to nursing care Child or spousal or elderly or patient abuse or neglect Allocation of resources (human, financial, equipment) Implementing managed care policies threatening quality of care Breaches of patient confidentiality or privacy (e.g., HIV status) Irresponsible or unethical or incompetent or impaired colleague Ignoring patient or family autonomy Patients or families uninformed or misinformed about treatment, prognosis, medical alternatives Rights of minors versus parental rights Discriminatory treatment of patients Unsafe equipment or environmental hazards Conflict in nurse or doctor relationship (or other professional relationship) Reporting unethical or illegal practice of health professional or health agency Implementing managed care policies threatening availability of care Component 3: Human rights issues Use or nonuse of physical or chemical restraints Issues involving advance directives Protecting patient rights and human dignity Informed consent to treatment Providing care with possible risk to RNs’ health (e.g., TB, HIV, violence) Note. From “The development and the psychometric evaluation of the Ethical Issues Scale,” by Fry and Duffy, 2001, Journal of Nursing Scholarship, 33(3), p. 276.

rights issues rather than end-of life issues. The most frequent issues were founded in patient care issue cat- egory. Of patient care issues that nurses encountered, staffing patterns that limit patient access to nursing care ( n = 6) was the most frequent ethical issue. In addition, nurses frequently encountered patient care issues such as conflict in nurse or doctor relationship ( n = 4), alloca- tion of resources (human, financial, equipment) ( n = 4), patient confidentiality or privacy ( n = 4), and incom- petent or impaired colleague ( n = 4). In human rights issue category, the following three items were identi- fied as the most frequent ethical issues: (a) protecting patient rights and human dignity ( n = 5), (b) providing care with possible risk to RNs’ health ( n = 5), and (c) informed consent to treatment ( n = 4).

When this review separated the setting into a gen- eral hospital versus operating room area, studies done in a general hospital setting identified other frequent ethical issues: dealing with an irresponsible or unethi- cal or incompetent or impaired colleague (Berger, Sev- erson, & Chvatal, 1991; Cook, Hoas, & Joyner, 2000), end-of-life care (Killen, 2002; Scanlon, 1990, 1994), and pain management (Omery et al., 1995; Scanlon, 1994).

Nurses in hospitals reported that they experienced fre- quent ethical problems related to patient confidential- ity or privacy issues as well as staffing patterns issues. TABLE 2. Frequent Ethical Issues Articles SettingEnd-of-Life Treatment Decisions Patient Care Issues Human Rights Issues Berger et al.

(1991)A hospital (U) Prolonging life with heroic measures a Staffing patterns, inappropriate allocation of resources, dealing with situations where patients are discussed inappro- priately, dealing with colleagues’ irresponsible activity Cook et al. (2000) Hospitals (R) Staffing patterns, patient family requesting more aggressive treatment options, a patient has unclari- fied confusing or no-code orders, colleagues are discussing patients inappropriately, dealing with an incompetent colleague Fry and Damrosch (1994)RNs in Mary- landQuality of patient life Staffing patterns, nurse–physician relationships Providing care that places the nurse at risk a Jenkins et al.

(2006)OR in army Staffing patterns, conflicts in the nurse–physician relationship a Providing care with risk to self, protecting patient rights and human dignity Killen et al.

(1996)OR Staffing patterns, nurse–physician relationship Providing care with risk to self, a informed consent, patient advocacy Killen (2002) OR End-of-life care, abortion issues Quality of care, truth telling, abuse of children/older people, confidentiality, privacy Informed consent, a HIV/ AIDS care, clinical safety King and Miskovic (1996)OR Staffing patterns, a allocation of resources, patients’ autonomy/advocacyInformed consent, occu- pational risk, patient self- determination act Omery et al.

(1995)A hospital (U) Pain relief/ management a Dealing with difficult patients, patient–physician– nurse relationship, care of noncompliant patient, cost of care to the patient Scanlon (1990) Hospitals (U) Do not resuscitate a death and dying.Professional practice issues, AIDS, allocation of resourcesPatients’ rights, AIDS Scanlon (1994) Hospitals in 50 statesEnd-of-life care, pain managementCost of containment issue, a confidentiality, incompetent, unethical, or illegal practices of colleagues Schroeter (1999) OR Impaired provider/potential for unsafe practice, misrepresentation by care provider, provider judgment/competencyConsent/advocacy, a disrespect for patient Note. U = urban area; R = rural area; RN = registered nurses; OR = operating room.aMost frequent item in the article. 72 Journal of Nursing Law Vol. 13, No. 3 TABLE 3. Rankings of Frequent Ethical Issues and Disturbing Ethical Issues Frequent Ethical Issues in All Reviews (N)Frequent Ethical Issues in Hospital Setting (N)Frequent Ethical Issues in Operating Room (N)Disturbing Ethical Issues (N) Staffing patterns that limit patient access to nursing care(6) Patient confiden- tiality or privacy (4) Protecting patient rights and human dignity(4) Prolong dying process with inappropriate measures(4) Protecting patient rights and human dignity(5) Staffing patterns that limit patient access to nursing care(3) Informed consent to treatment(4) Child or spousal or elderly or patient abuse or neglect(3) Providing care with possible risk to RNs’ health (5) Allocation of resources (human, finan- cial, equipment)(3) Providing care with possible risk to RNs’ health (3) Staffing patterns that limit patient access to nursing care a (2) Conflict in nurse or doctor rela- tionship (or other professional rela- tionship)(4) Irresponsible or unethical or incompetent or impaired col- league(3) Staffing patterns that limit patient access to nursing care(3) Acting against your own personal or reli- gious views(2) Allocation of resources (human, finan- cial, equipment)(4) Conflict in nurse or doctor rela- tionship (or other professional rela- tionship)(2) Conflict in nurse or doctor relationship (or other profes- sional relationship)(2) Irresponsible or uneth- ical or incompetent or impaired colleague a (2) Informed consent to treatment(4) Providing care with possible risk to RNs’ health (2) Providing care with possible risk to RNs’ health a (2) Irresponsible or unethical or incompetent or impaired col- league(4) End-of-life deci- sion(2) Treatment or nontreat- ment despite patient or family wishes(2) Patient confiden- tiality or privacy(4) Pain manage- ment(2) aFrequent ethical issues included in the disturbing ethical issues.

In contrast, this review found that perioperative nurses experienced more frequent ethical issues related to protecting patient rights and human dignity issues and informed consent than other issues (see Table 3).

Five of the reviewed articles reported disturbing eth- ical issues separately from the frequent ethical issues faced by nurses. Although these ethical issues would not frequently happen in their practice areas, nurses reported to be disturbed a great deal or quite a bit when these occurred. As shown in Table 3, the disturb- ing issues related to patient care issues and end-of-life issues. The disturbing ethical issues were (a) prolonging the dying process with inappropriate measures ( n = 4), (b) child, spousal, elderly, or patient abuse or neglect ( n = 3); (c) staffing patterns that limit patient access to nursing care (Berger et al., 1991; Jenkins, Elliott, & Harris, 2006); (d) acting against your own personal or religious views (Berger et al., 1991; Cook et al., 2000); (e) irresponsible, unethical, incompetent, or impaired colleague (Jenkins et al., 2006; Killen, Fry, & Damro- sch, 1996); (f) providing care with possible risk to RNs’ health (e.g., TB, HIV, violence) (Fry & Damrosch, 1994; Killen et al., 1996); and (g) treatment or nontreatment despite patient or family wishes (Berger et al., 1991; Cook et al., 2000) (see Table 4). The most of disturbing issues were not frequent ethical issues experienced by nurses. Disturbing issues often related to end-of-life issues: prolonging the dying process with inappropriate measures, acting against your own personal or religious views, and treatment or nontreatment despite patient or family wishes. Nurses reported being disturbed when patient abuse or neglect Park Ethical Issues in Nursing Practice 73 TABLE 4. The Most Disturbing Ethical Issues Articles SettingEnd-of-Life Treatment Decisions Patient Care IssuesHuman Rights Issues Berger et al. (1991) A hospital (U) Treatment despite patients’ objectives, prolonging life with heroic measures, acting against personal principlesInadequate staffing patterns, a incidents of patients’ abuse Cook et al. (2000) Hospitals (R) Acting against personal principles, a prolonging life with heroic measuresPatient family requesting more aggressive treat- ment options, cost- containment issues that threaten quality if care, treatment or nontreatment despite patient or family wishes Fry and Damrosch (1994)RNs in Maryland Prolonging life with extraordinary measures, a quality of patient lifeCost-containment issues that threaten quality of care, child/spousal / elderly/patient abuse or neglectProviding care with risk to self a Jenkins et al.

(2006)OR in army Dealing with incom- petent or impaired colleagues, a conflicts in the nurse–physician relationship, staffing patterns, unsafe equipment and /or environment hazards Killen et al. (1996) OR Prolonging life with extraordinary means, a treatment over family objectivesIrresponsible/incom- petent colleagues, patients and families who are uninformed or misinformed about treatment plans, prognosis, child/other abuseProviding care with risk to self Note. U = urban area; R = rural area; RN = registered nurses; OR = operating room.aMost frequent item in the article.

of patient care issues occurred. Furthermore, the review found that the staffing pattern and incompetent, impaired colleagues issues and providing care with pos- sible risk to RNs’ health were disturbing issues as well as frequent issues that were faced by nurses.

Approaches/Resources This study also reviewed the approaches and resources that nurses have taken to solving ethical issues. Four articles reported that most nurses used their own per- sonal values to solve ethical issues (Berger et al., 1991; Cook et al., 2000; Killen et al., 1996; Schroeter, 1999) (see Table 5). In addition, most nurses discussed ethical problems with nursing peers (Berger et al., 1991; Cook et al., 2000; Jenkins et al., 2006; Killen et al., 1996; Scanlon & Fleming, 1990). One study reported that 68% of respondents reported talking to a higher administra- tive authority (e.g., managers, supervisors, or directors) TABLE 5. Approaches and Resources for Ethical Issues Articles Setting Sample Sample Size (N)Measures Approaches/Resources EN Comments Berger et al. (1991) A hospital in an urban areaNurses 52 A questionnaire (Ethical Issues in Nursing )Own personal values (88%) Nursing colleagues (97%)(+) Recommendation: nursing ethics rounds, educational opportunities/programs, a shared governance model Cook et al. (2000) 21 hospitals in rural areaNurses 204 A 14-page surveyOwn personal values (48%) Nursing colleagues (87%), nursing leadership (77.4%), physicians (70%), clergy (7%)(+) Education topics: profes- sional responsibilities, infor- mation on patient rights, privacy and confidentiality, information regarding truth telling Fry and Damrosch (1994)RNs in MarylandNurses 462 The survey instrument Nursing peers (71%), nursing leadership (51%), physicians (56%), other professionals (39%), ethics committee (11%)(+) Education topics: empower- ment of nurses, content/ interpretation of nurses’ ethical codes, care of HIV/ AIDS patients, treatment/ nontreatment of the dying and/or elderly, quality of life, use/removal of life support systems, profes- sional responsibilities, care of dangerous and/or offensive patients, ethical decision making, pain man- agement, moral develop- ment/ reasoning Jenkins et al.

(2006)Army in United StatesCRNAs ANC = 74; DAC = 22 Modified Ethical Issue Scale (EIS)An informal approach Nursing peer (84.5%), nursing leadership (54.6%), ethics committee (5.2%)(+) Education topics: ethics of triage, conduct of the health care provider as a prisoner of war, the role of nurses as advocates, ethical decision making, quality of life Killen et al. (1996) OR/recovery roomPORNs 373 Pre-EIS Nurses’ personal codes of ethics Nursing peers (73%), nursing leadership (57.7%), physicians (50%), other professional (30.8%), family or friends (30.8)(+) Education topics: patient’s right to information, treat- ment of the dying and the elderly, treatment of the deformed and handicapped, pain management, patient’s right to demand or refuse treatment Killen (2002) The members of the AORNPORNs 214 A cross-sectional surveyEthical principles: auton- omy (33.8%), nonma- leficence (42.9%), fidelity (9.8%)NA Recommendation: adminis- trative support King and Miskovic (1996)The members of the AORN in BaltimorePORNs 217 Ethical Issues: A Survey of Periop- erative NurseNA (+) Recommendation: educa- tion about the American Nurses Association code of ethics Omery et al.

(1995)A medical center in an urban areaNurses 794 The Ethical Issue and Resources SurveyNA NA NA Scanlon (1990) Institutions in an urban areaDirec- tors of nursing71 A questionnaire Formats addressing ethical issues in nursing: nursing meeting (66%), in-service education (18%), hospital committees (9%), individu- al discussion/consultation (9%), hospital ethics committee (9%)(+) Used ethics education methods in hospitals:

orientation program (35%), continuing education programs (42%) Scanlon (1994)RNs in 50 states (hospitals)Nurses 934 A written survey Literature (44%), ethics committees (42%), continuing education (39%)(+) NA Schroeter (1999) PORNs in southeastern WisconsinPORNs 40 A descriptive self-report ques- tionnaire, a scenario-based surveyPersonal values, work experiences, nursing code of ethics, professional education A higher administrative authority (68%), direct confrontation (21%)NA NA Note. EN = education need; (+) = expressed education need; CRNAs = certified RN anesthetists; ANC = Army Nurse Corps; DAC = Department of the Army Civilian; OR = operating room; PORNs = perioperative RNs; AORN = Association of Perioperative RNs; NA = not applicable. 76 Journal of Nursing Law Vol. 13, No. 3 (Schroeter, 1999). A small percentage of responding nurses had experience consulting with ethics commit- tee (Fry & Damrosch, 1994; Jenkins et al., 2006; Scan- lon & Fleming, 1990) (see Table 4). However, one study reported ethics committees as one of main resources that nurses consider available when facing an ethical problem (Scanlon, 1994).

Moreover, most of studies (n = 8) reported nurses’ educational need related to nursing ethics. In four stud- ies, the nurses indicated the need for the following edu- cation topics: (a) professional responsibility, (b) patient rights, (c) ethical code/principles, (d) treatment/non- treatment of the dying, (e) patient advocacy, (f) ethical decision making, and so on (see Table 4).

DISCUSSION Most of ethical issues mentioned in the reviewed articles can be classified into three categories in the EIS: end-of-life issues, patient care issues, and human rights issues. Frequent ethical issues faced by nurses related mainly to patient care issues and human rights issues, whereas the disturbing issues frequently related to end-of-life issues. The most frequent issues are staff- ing patterns, protecting patient rights and human dig- nity, providing care with possible risk to RNs’ health, conflict in the nurse or doctor relationship, and alloca- tion of resources. The disturbing ethical issues include prolonging the dying process, child or elderly abuse (neglect), staffing patterns, acting against your own personal, and impaired colleagues.

Nurses in daily practice face various ethical issues.

In particular, as technology becomes more compli- cated and medical care resources become more limited, the concern over “staffing patterns” or “allocation of resources” is centered frequently on nurses, reflecting the industry-wide trend of balancing cost and quality (Killen et al., 1996). The issues are also ranked among the most disturbing issues; that is, it is not a rare event that nurses are directly involved in these most disturb- ing issues. Thus, nurses may need special support to ethically respond to the issues that are particularly dis- turbing to them.

Nurses in hospitals reported that they experienced frequent ethical problems related to patient confiden- tiality or privacy. In contrast, perioperative nurses more frequently encountered ethical issues related to protecting patient rights and the human dignity issue and informed consent than other issues. The frequency of ethical issues may differ depending on the nurses’ specialty areas. Redman and Fry (2000) reported that the main ethical conflict was experienced differently by nurses in a particular role or setting. The findings indicate that ethical decision-making resources need to be made available to nurses in a specialty area in view of their higher-frequency issues.

In terms of how the nurses handle their ethical issues and what resources help nurses handle these issues, most of studies show that nurses deal with ethical issues on the basis of their own values and receive guid- ance from nursing peers rather than from ethics com- mittees. The fact that nurses use their personal values most frequently to clarify ethical issues draws atten- tion to necessity of nurturing qualified nurses in ethi- cal decision making through education. Furthermore, most of the nurses in the reviewed studies recognized the necessity of ethics education related to the ethical issues that they face. Therefore, nursing education should develop pragmatic ethics programs based on the ethical issues and the needs of nurses. In particular, the frequent ethical issue should be discussed in the ethics curriculum of undergraduate programs for developing skills in recognizing and analyzing the issues.

The code of ethics of the American Nurses Asso- ciation (ANA, 2001) deals with moral accountability as a nursing professional based on ethical principles.

According to study findings, nurses have not recog- nized the code of ethics as their reference when ethical issues are encountered. However, nurses simultane- ously expressed education needs regarding professional ethical responsibility and ethic codes. Ethics educators in nursing programs need to explain the ANA’s code of ethics as well as ethical principles. The code of ethics will provide a guide for nurses when facing an ethical dilemma.

During the process of review in this study, the reviewer did not include several articles related to specialty areas because they did not deal with ethical issues in terms of frequency. This study may not have identified all relevant studies. Furthermore, this review has limitations related to information about nurses’ eth- ical issues in other special areas, except the operating room. Therefore, the author recommends further study related to frequent ethical issues that nurses face in a particular role or setting. Future study can help nurses understand ethical issues in special areas and allows developing ethics education focused on specific issues in a particular nursing practice. Furthermore, new ethical issues in nursing are emerging with changes in our society. This study shows ethical issues frequently repeating in nursing in the past two decades and may not include some current issues. Therefore, nursing educators and researchers continuously need to update the ethical issues into nursing education. Park Ethical Issues in Nursing Practice 77 The ethical issues measured by frequency provide information about the specific ethical issues of nurses in active practice experience. Therefore, the informa- tion can serve to intensify awareness of the issues in clinical areas as well as education areas. Gilbert (1982) pointed out the identification of ethical issues as one of critical content areas in ethics education. The findings in this article can be used to design and improve eth- ics education programs for nursing students as well as practice nurses as pragmatic evidence. REFERENCES American Nurses Association. (2001). Code of ethics for nurses with interpretive statements.

Silver Spring, MD: American Nurses Publishing.

Berger, M. C., Seversen, A., & Chvatal, R. (1991). Ethical issues in nursing. Western Journal of Nursing Research, 13 (4), 514–521.

Briggs, L., & Colvin, E. (2002). The nurse’s role in end-of-life decision-making for patients and families. Geriatric Nurs- ing, 23 (6), 302–310.

Bunch, E. H. (2001). Hidden and emerging drama in a Norwe- gian critical care unit: Ethical dilemmas in the context of ambiguity. Nursing Ethics, 8 (1), 57–67.

Christensen, A. (2002). Legal and ethical issues confronting oncology nursing. Seminars in Oncology Nursing, 18(2), 86–98.

Cook, A. F., Hoas, H., & Joyner, J. C. (2000). Ethics and the rural nurse: A research study of problems, values, and needs. Journal of Nursing Law, 7 (1), 41–53.

Fry, S. T., & Damrosch, S. (1994). Ethics and human rights issues in nursing practice: A survey of Maryland nurses.

Maryland Nurse, 13 (7), 11–12.

Fry, S. T., & Duffy, M. E. (2001). The development and the psychometric evaluation of the Ethical Issues Scale. Jour- nal of Nursing Scholarship, 33(3), 273–277.

Gilbert, C. (1982). The what and how of ethics education. Top- ics in Clinical Nursing, 4, 49–56.

Jenkins, C. L., Elliott, A. R., & Harris, J. R. (2006). Identifying ethical issues of the Department of the Army Civilian and Army Nurse Corps certified registered nurse anesthetists.

Military Medicine, 171 (8), 762–769.

Killen, A. R. (2002). Stories from the operating room: Moral dilemmas for nurses. Nursing Ethics, 9 (4), 405–415.

Killen, A. R., Fry, S. T., & Damrosch, S. (1996). Ethics and human rights issues in perioperative nurses: A subsample of Maryland nurses. Seminars in Perioperative Nursing, 5 (2), 77–83.

King, C. A., & Miskovic, J. M. (1996). Ethical issues: A survey of perioperative nurses. Seminars in Perioperative Nursing, 5 (2), 84–91.

Omery, A., Henneman, E., Billet, B., Luna-Raines, M., & Brown-Saltzman, K. (1995). Ethical issues in hospital-based nursing practice. The Journal of Cardiovascular Nursing, 9 (3), 43–53.

Redman, B. K., & Fry, S. T. (2000). Nurses’ ethical conflicts:

what is really known about them? Nursing Ethics, 7(4), 360–366.

Scanlon, C. (1994, November–December). Ethics survey looks at nurses experiences. The American Nurses , 22.

Scanlon, C., & Fleming, C. (1990). Confronting ethical issues:

A nursing survey. Nursing Management, 21 (5), 63–65.

Schroeter, K. (1999). Ethical perception and resulting action in perioperative nurses. AORN Journal, 69 (5), 991–1002.

Vaughan, R. H. (1935). The actual incidence of moral problems in nursing: A preliminary study in empirical ethics (Studies in Nursing Education, Vol. II, Fasc. 2). Washington, DC:

Catholic University of America.

Woods, M. (2005). Nursing ethics education: Are we really delivering the good(s)? Nursing Ethics, 12 (1), 5–18.

Wright, F., Cohen, S., & Caroselli, C. (1997). Diverse deci- sions: How culture affects ethical decision making. Critical Care Nursing Clinics of North America, 9 (1), 63–74 .

Biographical Data. Mihyun Park, MSN, RN, is a doctoral stu- dent at the University of North Carolina, Chapel Hill, North Carolina. She is also a Catholic Sister in Sisters of Our Lady of Perpetual Help (SOLPH), South Korea.

Correspondence regarding this article should be directed to Mihyun Park, MSN, RN, University of North Carolina at Chapel Hill, School of Nursing, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail: [email protected] Copyright of Journal of Nursing Law is the property of Springer Publishing Company, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.