Title

Nursing Leaders’ Ethical Decision-Making About Professional Boundaries and Nurse-Patient Relationships: A Mixed Methods Explanatory Sequential Design

Date of Degree

5-2019

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Program

Education

Advisor

Norman S. St. Clair

Advisor

David S. Fike

Advisor

Alison A. Buck

Advisor

Laura R. Munoz

Abstract

The purpose of this mixed methods explanatory sequential design study was to ascertain nursing leaders’ knowledge and skill in ethical decision-making when evaluating and managing professional nurse-patient relationship boundaries. It was also the purpose of this study to better understand nursing leaders’ perception of moral, cognitive, and organizational factors influencing their ethical decision-making in evaluating and managing professional nurse-patient relationships, with the intent of generating a theory grounded in the views of the participants as a final outcome of the study. The two theories, virtue ethics and self-efficacy comprise the ethicality construct of the conceptual framework explaining the nurse leaders’ beliefs about themselves and their ability to conduct ethical decision-making. The professional boundaries construct of the conceptual framework delineates the attributes and expectations of nursing as a profession, thus further explaining the nurse leaders’ role in ascertaining ethical professional boundaries among nurses and patients. Participants in the quantitative phase of this study included 28 female and 13 male nurse leaders selected by a convenience sampling approach from San Antonio Military Medical Center, Brooke Army Medical Center, Fort Sam Houston, Texas. The participants were asked to complete a researcher designed Ethical Decision-Making Survey Instrument consisting of two scenario based vignettes with six Likert questions per vignette and a demographic questionnaire. The Ethical Decision-Making Survey Instrument was designed to assess nurse leader’s ethical decision-making about nurse-patient relationships and professional boundaries. Data analysis revealed by 48 bivariate Pearson product-moment correlation coefficients that the greater the number of years of work experience as an RN and the greater the number of years of work experience as a nurse manager, the more comfortable a nurse manager felt speaking with a nurse about his/her behavior regarding nurse-patient professional boundary transgressions. Additionally, the greater number of years of work experience as a nurse manager, the more knowledge she/he believed she/he had to appropriately manage nurse-patient professional boundary transgressions. Calculating six paired-samples t-tests revealed significantly greater mean scores for a nurse leader’s belief that nurses violate boundaries and exhibit unethical behavior in the scenario depicting a nurse involved in a personal relationship with a patient than a flirtatious relationship. Calculating 48 mixed between-within subjects ANOVAs revealed substantial main effects for nurse manager’s ethical decision-making in determining violations of nurse-patient professional boundary breaches and the unethicality of the behavior revealing higher scores on the scenario depicting a nurse involved in a personal relationship with a patient than a nurse involved in a flirtatious relationship with a patient. The qualitative phase was designed to further explain the results of the quantitative analysis. Participants in the qualitative phase of this study included seven female and zero male nurse leaders initially selected through purposeful sampling followed by a snowball sampling approach from San Antonio Military Medical Center, Brooke Army Medical Center, Fort Sam Houston, Texas. The participants were interviewed utilizing 12 guided open-ended questions with the aim of assessing moral, cognitive, and organizational factors influencing ethical decision-making about nurse-patient relationships and professional boundaries. Thematic analysis revealed the following themes: (a) ascribing conscience, (b) codifying knowledge repertoire, (c) summoning support systems, and (d) weighing elements affecting judgment. Each theme is discussed in depth and supported by exact participant quotations. The study culminates in a grounded theory. The study concludes with implications for nursing leadership, health care organizations, and nursing academia. As a result of the study findings, recommendations are highlighted that may promote a skill set conducive to improving nursing leader’s ethical decision-making about nurse-patient relationships and professional boundaries.

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