_------'~L__ _

o ETHICAL DECISION-MAKING IN ANEMERGENCY DEPARTMENTFINDINGS ON NURSING ADVOCACYPam McGrath, Central Queensland UniversityEmma Phillips, Central Queen sland University

The purpose of this article isto share with the reader the specific findings on the role ofnurseas consumer advocate from astudy on ethical decision-making inan emergency department (EDI.Qualitative interviews were conducted with11 health professionals (doctors and nurses) workinginthe ED ofahospital.The interviews were audio-recorded, transcribed verbatim and thematicallyanalysed.

In ED, where the decision-making isdescribed as medico-centric, advocacy ipso facto necessitatesa challenge to doctor decision-making. The findings indicate that ED nurses' experience withadvocacy varied depending on the democratic qualities and communication skills ofthe particulardoctor who had care of the consumer. It is noted that seeing the need for advocacy does notnecessarily translate into effective action, as management support is essential forproductiveadvocacy. A phenomenon ofthe desirenot to rock the boat was reported. The findings indicatethat the support ofother nurses isessentialforadvocacy and affirm the importance offocusingon theethical nature of the organisation as opposed toan exclusive focus on the individual.

INTRODUCTIONAdvocacy for clients is viewed as a key ethical obligation and an essential function fornursing (Gaylord and Grace 1995 ; Hanks 2007; McGrath and Walker 1999; Shirley2005) . Informed by early writers such as Curtin (1979), Gadow (1980), and Kohnke(1982), advocacy is a relatively new role for nurses (Hanks 2005). However, the role ofnurse as consumer advocate is now not only widely accepted in the profession aroundthe world (McSteen and Peden-McAlpine 2006) but is also described as an indicator ofexcellence in nursing practice (Hewitt 2002; Vaartio et al. 2006).

Referred to as an ethic of practice (Gaylord and Grace 1995; McSteen and Peden­McAlpine 2006), there is a strong connection between the notion of advocacy and ethicaldecision-making for nurses. At the core of this concept is the moral commitment to caringand an ethical concern with translating the principle of autonomy into practice (McSteenand Peden-McAlpine 2006). Prior research by the present authors on the topic of ethical

16.1 MONASH BIOETHICS REVIEW. VOLUME 28. NUMBER 2.2009 MONASH UNMRSIlY EPRESS

decision-making in an acute medical ward (McGrath et. al. 2006; McGrath and Hende­rson 2008b; McGrath and Holewa 2006) indicated that advocacy is seen as central toethical praxis for nurses and described in holistic terms as the representation of theconsumer in the context of the family through the processes of respecting choice, inform­ation-giving, explaining, communicating, maintaining professionalism and providingcomfort (McGrath et. al. 2007) . The authors received strong interest in the findings fromthe original study, along with requests for the research to be extended to other hospitalsettings. As a consequence, the work has now been repeated in an emergency department(ED). This setting was chosen as, to date, there has been scant work completed on theethical decision-making of health professionals in ED departments. The purpose of thisarticle is to share with the reader the specific findings on advocacy from the ED study,which both resonate with and differ from the prior insights from acute medicine. Theart icle is a further response to Atwal and Calwells' (2005) call for further research onthe interface of medico-centrism and nursing advocacy.

The work involved qualitative interviews with health professionals working in EDat Redland Hospital, Queensland Australia (Hospital) . The Hospital is a 140-bed generalhospital situated in Cleveland on the eastern outskirts of Brisbane. The Hospital, whichis part of the Bayside Health District Service, provides Emergency, Medicine, Surgery,Obstetrics and Gynaecology, Paediatrics and Mental Health services.

THE RESEARCH

THE AIM

The purpose of this article is to share with the reader the specific findings on the role ofnurse as consumer advocate from a study on ethical decision-making in an emergencydepartment (ED). The overall aim of the study is to explore and document the healthprofessionals' organisational processes for responding to ethical issues in ED of thehospital. The study builds on previous pilot work with the same aim and methodologyconducted in an acute medical ward .

The study, funded by an Industry Grant, represents collaboration between the Inter­national Program of Psycho-Social Health Research (lPP-SHR), Central Queensland

University and Redland Hospital.

PARTICIPANTS

All of the health professional partic ipants were staff working full-time in ED at theHospital and included a purposive sample of the team of professionals working in ED.

ETHICAL DECISION-MAKING INAN EMERGENCY DEPARTMENT ARTICLE 16.2

There were four doctors (n= 4) and seven nurses (n=7) interviewed . Because the parti­cipants were enrolled from a small identifiable group at the Hospital the informed consentprocedures gave a strict commitment to confidentiality and a guarantee that no identifyinginformation would be presented or published with the findings. Hence further demo­graphic description will not be provided to protect the identity of the participants.

The participants were enrolled through the Project Officer for the study who wasunder contract with the University and thus independent of the Hospital. The ProjectOfficer had meetings with representatives from the different disciplinary groups (medicineand nursing) to discuss the study. She provided written Project Descriptions of the project,invited voluntary participation in the research and followed-up enrolment of interestedparticipants. There was no screening of participants. Prior to interviewing participantswere informed of their ethical rights (e.g., informed consent, confidentiality, right towithdraw) before agreeing to participate and a written consent was obtained prior tothe interview. The University ethics committee and the Queensland Health DepartmentHuman Research Ethics Committee approved the study.

RESEARCH DESIGN

The theoretical framework for the research was situated in descriptive phenomenology,which seeks to gain insights on a phenomenon from the insider's subjective descriptionnot affected by prior assumptions (Holloway 2008; Giorgi and Giorgi 2004). In thiscase, the phenomenon was the notion of health care ethics and how this notion was op­erationalised in the hospital system. Descriptive phenomenology is particularly appropriatewhere little is known about an issue (Creswell 2003), and so was well suited to a qualit­ative study of ethical definition and process where there was scant previous research lit­erature. As Holloway (2008) clearly states, phenomenology is not a research method initself, but rather an attitude that informs a response to the phenomenon under study.Thus, the following discussion outlines the method that was taken to operationalise theaim of a descriptive phenomenological understanding of the processes of hospital ethics.

INTERVIEWS

The exploration of appropriate organisational processes for responding to ethical issueswas conducted through an iterative, phenomenological, qualitative research methodologyusing open-ended interviews conducted at the time' and location of the participant'schoice. As Kvale (2007) explains, interviews are the best form of generating data in de­script ive phenomenology. The interviews were conducted by a psychosocial researcherwith a background in Bioethics employed by the University and thus independent of the

16.3 ETHICAL DECISIDN-MAKINlrINANEMERGENCY DEPARTMENT ARTIClE

Hospital. The interviews were conducted either by speaker-phone or in the privacy of ameeting room at the Hospital, depending on the choice of the particular participant.

The health professional participants were encouraged to talk about how they woulddefine the notion of eth ics and to describe the strategies they used to respond to ethicalconcerns during their work at the Hospital. The interviews were informed by the principles

of 'phenomenological reflection' as outlined in the work of Van Manen (1990) . The in­terviews lasted for approximately one hour and were audio-recorded. The interviews

were transcribed verbatim by a research assistant independent of the Hospital.

ANALYSIS

The language texts were then entered into the QSR NUD*IST (N5 1995) computer

program and analysed thematically. All of the participants' comments were coded into'free nodes' which are category files that have not been pre-organised but are 'freely'created from the data. The list of codes was then transported to a Word Computer Pro­

gram (Word 97) and organized under thematic headings. The coding was established by

an experienced qualitative researcher who is an expert in the area of Bioethics andcompleted by the Project Officer who has extensive experience with coding qualitative

data. There was complete agreement on the coding and emergent themes. The cod ingfor each of the participant groups was completed separately. There were 38 free nodes

created from the doctor transcripts and 81 free nodes created from the nursing transcripts.The findings presented in this article represent the relevant codes from nursing and doctorparticipants that provide insights about the process of nursing advocacy in ED.

As inductive, phenomenological, qualitative work, the reporting of findings is basedon a comm itment to the bracketing of researcher's assumptions and focusing on the es­sence of the phenomenon from the participants' point of view (Gearing 2004). Thus anarrative account dominates, with a clear separation between the presentation of theexact words of the participants in the findings section and the interpretation in the dis­cussion section (Grbich 2007).

SETTING THE STAGE - SUMMARY OF PRIOR FINDINGS

One of the key findings from the study which is detailed elsewhere (McGrath andHenderson 2008a) is that health professionals are not only able to clearly articulate no­

tion s of ethics, but that the notions expressed by an intra-disciplinary diversity of parti­cipants share a common definit ional concept of ethics as 'consumer-centered care '. Bothprofessional groups (medicine and nursing) from this study indicated that there is aprinciple guiding their ethical sense of the 'good' or the 'ought' and that is to act in a

ETHICAL DECISIDN·MAKING INAN EMERGENCY DEPARTMENT ARTICLE 16.4

way that furthers the interests of consumers and their families. This finding was originally

articulated in a pilot study in an acute medical ward (McGrath and Henderson 2008a)

and has been affirmed by this study, which involved an extension of that study into ED.

As a background to the present discussion it is important to note that further findings

from the study indicated a high level of health professional satisfaction with ED as a

supportive environment for ethical decision-making. The factors reported to be contrib­

uting to this satisfaction included effective leadership, effective communication processes,

respect for other team members, an environment supportive of disagreement and the

minimal staff turnover associated with a small regional hospital. Of key importance to

th is discussion, however, is the finding that the doctors were the decision leaders and

had the final say. Doctor reported seeking advice predominantly from other doctors

rather than nurses. As the following findings ind icate, in certain situations this can lead

to conflict between the nursing and medical profession and a need for nurses to take an

advocacy stance to represent consumer and family wishes . This discussion moves from

the generic findings on the team cohesion, submitted for publication elsewhere, to explore

specific examples of ED ethical practice perceived by nursing participants to require

consumer advocacy. In summary, nursing advocacy is seen as the ethical practice of

representing consumer and family needs and wishes to ensure that medical decision­

making is cognizant of consumer wishes.

As nursing advocacy is, by definition, a process concerned with nurses representing

the needs of their consumers to doctors, most of the comments in the following findings

are from nurses and thus indicated by an (n) at the beginning of the quote. However,

there are some doctors' statements affirming the nurses' notions of medico-centrism

(indicated by an (m) at the beginning of the quote) .

FINDINGS

COMMUNICATING THE CONSUMER MESSAGE

At the core of the nursing advocacy ethical praxis is the process of effectively communic­ating the consumer message to the medical decision-makers. Many, but not all, of the

nursing participants indicated that ED is a supportive environment for engaging in ad­

vocacy communication. As one nurse summed up: ' In the area I work in I feel that people

do listen to everybody else' . For most nurses the ED.subculture is seen as supportive of

individuals voicing their opinions - an important prerequisite for effective advocacy. For

example:

16.5 ETHICAL OECISION·MAKING INAN EMERGENCY DEPARTMENT ARTICLE

(n) Yeah, I think it works pretty well in the group itself. Yeah I feel

we've got a great thing here, I feel very supported in speaking my mind.

That's why I choose to work here.

However, special mention was made of the fact that the opinions of the senior nursesare especially held in respect and so they are in a strong position to effectively commu­nicate on behalf of consumers and their families. This was noted by junior staff, for ex­ample:

(n) We do know who the senior doctors are and I feel that the nursing

staff respect their experience. But similarly the medical staff respect

the opin ions of especially the senior nursing staff as well.

It was also noted by senior nursing staff, for example:

(n) I guess I'm lucky in a way because I'm one of the senior nurses in

here and I've probably been used to communicating at a higher level

anyway so I don 't have any problems being assertive or telling them

[doctors] what they should be doing [on behalf of consumers and their

families].

Thus, many potential advocacy issues are dealt with at the level of effective interdiscip­linary communication:

(n) I think by sitting down and talking with staff is probably the best

way to try and resolve the issues [relevant to nursing advocacy con­

cerns] .

As noted previously, one of the key themes that emerged from the findings was thatthere is a strong, doctor-led group cohesion where professionals generally share agreementon appropriate interventions, have opportunities such as staff and nursing meetings toexpress concerns and value consulting consumers and their families to ascertain theirneeds and desires. In short, there are many healthy communication processes that deflectconflict and the need for nursing advocacy.

ETHICAL DECISIDN·MAKING INAN EMERGENCY DEPARTMENT AIlT1CLE 16.6

ADVOCACY PRAXIS - A DIFFICULT CHALLENGE

However, even in the ED environment that was described as supportive of differencesof opinion , it was noted that there could be difficulties associated with taking an advocacy

stand:

(n) You'd voice it [concern about the consumer's welfare] . But that's

often what gets me into problems because I would push that.

For some nurses, seeing the need for advocacy did not necessarily translate into effective

action :

(n) I always see it [the need for advocacy] and I think it's the most

difficult part for me is that I can see it and it gets me nowhere.

The first step of actively listening to consumers and families was reported as easybut the translation of this into advocacy action often difficult, as one nurse expressed:

(n) The big dilemma is though that I may as a nurse find out very

nicely what people want but then when it comes to being, as we like

to be, a consumer advocate I feel it falls completely in the water. I

cannot. I very rarely can prepare consumers' wishes and rights into

reality.

Some gave examples of ineffective advocacy action, for example:

(n) But often I will write a letter or something and if then the letter

comes back and they say... or I may speak to someone higher up.. .

and if the response is fairly negative or 'well there 's noth ing we can

do about it' - then I will leave it.

THE PROBLEM OF MEDICO-CENTRISM

From the findings, it appeared that the nub of the problem is the strong medico-centrismthat reinforces the doctors' control in decision-making and marginalizes the voices ofnurses. As one nurse stated:

(n) It is the physician and consumer relationship that is very strong

and they [doctors] certainly don 't want thai to be disturbed ... the

decision has to be made by them.

16.7 ETHICAL DECISIDN·MAKING INAN EMERGENCY DEPARTMENT AJlT1ClE

The doctors interviewed for the study also noted that the decision-making is medico­centric, for example:

(m) ... for the vast major ity of the time I'll discuss it [ethical concern

relevant to nursing advocacy concerns I with one of the senior doctors

and then formulate a plan. And then yes, it is about trying to implement

the plan the best way basically.

The only reason given for involving the senior nurse was a lack of other docto rs availableto consult, as one doctor explained :

(m) Occasionally there's situat ions where you're by yourself and would

be absolutely delighted to have some senior nurses with me to help,

to bounce ideas off and things, but ....

Most ethical situations relevant to nursing advocacy concerns are viewed by EDdoctors as not requiring consultation other than with other doctors, for example:

(m) I probably haven't been confronted with any situation which is

complex enough to warrant that kind of broad based consultative

approach. Any ethical questions so far have been simple enough to

just be dealt with between myself and whatever other senior doctor

that's available .

However, nurses reported that they had different experiences in relation to advocacydepending on which doctor they were working with. As the following participant indic­ated, there is individual variation in doctors' ability to listen to nurses when advocatingfor their consumers:

(n) Yeah, they know that we're the closest people to the consumers

and we are the consumer's advocates . I mean a lot of doctors do listen

to us, but there are definitely ones who don't. There are certain doctors

who won't listen to you and won't take any of your advice. But then

there are others who really take on board what you think.

ADVOCACY BURN·OUT

One particularly disillusioned nurse provided direct statements about the oppressionassociated with being marginalized in the medico-centric decision-making process.

ETHICAL DECISION-MAKING INAN EMERGENCY DEPARTMENT ARTICLE 16.8

(n) But I have had a personal issue here with one of the doctors and I

learned very clearly then that you 're just such a small cog in the

workforce. And that's what the organisation really gave me to under­

stand. And it was between a doctor and a nurse ... that I was of very

little consequence. And that sounds very depressing but that was the

reality.

For this nurse, the consequence was to lose the enthusiasm for consumer advocacy:

(n) So I tend since that happened - I tend to let things [advocacy] go

a bit more. The fire in the belly is gone .

However, other nurses indicated that they had not experienced a serious problem withbeing a consumer advocate in ED that had led, as yet, to such a tense and isolated situ­

ation:

(n) I haven't come across that situation myself yet.

THE TRADE OFFThroughout the data there were references to a phenomenon whereby a need for advocacy

perceived by the nurse was either silenced or suppressed by a desire to maintain peacefulteam working relationships. This priority given to what is colloquially known as 'not

rocking the boat' over an advocacy response to an ethical concern is termed, for thepurpose of this article, the 'trade off ' . One nurse explained this idea of the 'trade off'when asked what would happen if the efforts of advocacy were causing tension withinthe ED team as follows:

(n) And I recognise that you have to work with people and that is an

overriding thing . I have a lot of difficulties with it [not acting on an

ethical sense of what the consumer wantsI but that's just the reality .

(emphasis added)

As this is an important issue posited by many of the participants the interviewersummarized the insight, giving participants the opportunity to affirm, disagree or clarify.As can be seen by the follow ing example, the participants affirmed the notion of a 'tradeoff' :

16.9 ETHICAL DECISIDN·MAKING INAN EMERGENCY DEPARTMENT ARTIClE

(n) [Interviewer: What I'm hearing is that there is a trade off between

maintaining the goodwill and keeping the cohesion of the work group,

and being able to advocate effectively for your consumer, that you can

only push it so far and then you've got to adhere to keeping the

workgroup relationships okay . $0 there 's -a trade off there. Is that a

correct summary of the issue?] That's right . Yes, that's exactly right .

That's exactly how I see it.

An example of a ' trade off' in relation to end-of-life ethical decision-making is explained

by the following nursing statement:

(n) ... within a team the nurs ing staff would say: 'this person or their

family has declared their wishes that the person doesn 't want to be

resuscitated'. And we would make that known to the medical team.

If they wanted measures to be taken to try and resuscitate the person,

then, yes, I would probably take part.

One of the key ideas posited by many of the nurses was that the team is seen as

positive because people share similar ideas:

(n) I must admit I don't have too many problems. I think in the ED

here most people think along the same lines. It's a pretty good team .

However, maintaining the positive team spirit was seen as so important it could putat risk dealing with the 'real issues', as one nurse explained:

(n) They constantly seem to talk about that you work all together ­

but not deal with the real issues. They say 'oh no that isn't an issue

we need to just address '. [Interviewer clarifying the statement: $0 really

there 's more the pressure to just get on with it?] That's right.

One nurse indicated that an individual nurse may have to pay a high cost of leaving theposition if the tension was not controlled, as can be seen by the following statement:

(n) And I can move around. You can work around and nurses are

needed everywhere, but you can't keep doing that and so I would stop

[i.e. not advocate] . And so be it!

ETHICAL DECISIDN·MAKING IN AN EMERGENCY DEPARTMENT ARTICLE 16.10

Accordingly, even though the ED team was seen as a supportive environment, advocacy

could be an isolating experience, as one nurse explained:

(n) I don 't have anyone [to go to] that I know of. I like to work in a

team so I get a lot of support from the team . But in those sort of issues

in the end if you have the problem with it - you deal with it.

ADVOCACY - ANURSING RESPONSIBILITY

It was suggested that more nurses should embrace advocacy for their consumers:

(n) And maybe as nurses we have to show them much more. We need

to take responsibility for what we do - much more than we actually

in reality are doing now.

A truly multi -disciplinary approach was noted as a necessary prerequisite to integrate

nursing advocacy into the system so that nurses are not 'bystanders', but rather active

participants in the ethical decision-making process on behalf of consumers and their

families. As one nurse eloquently stated:

(n) I think we need to get away from the fact that only one person [i.e.

the doctor] is the final decision-maker. I think that would do good for

nurse s because then nurses would be able to say, 'Hey we can't always

stand outside this circle being uninterested bystanders' . 'We have a

duty to partake in this decision making because we feel that we're

worthwhile. You playa part - It's not such a token part.' And that

you say: 'Well we were asked and the decision is not just made by one

person' .

DISCUSSION

Nursing advocacy is documented as an inherent element of professional nursing ethics

(Vaartio et al. 2006) . The discussion of advocacy in this article needs to be set in the

context of the wider find ings from the study indicating that health professionals in ED

define ethics as 'consumer-centered care'. Thus, the rationale for advocacy provided by

participants in this study is based on the nurses' ethical responsibility for ensuring quality

care for consumers. This resonates with the work of Gaylord and Grace (1995), who

argue that advocacy for nursing stems from a philosophy of nursing in which nursing

practice is the support of an individual to promote his or her own well-being, as under-

16.11 ETHICAL DECISION -MAKING INAN EMERGENCY DEPARTMENT ARTICLE

stood by that individual. As Mitty (1991) writes, advocacy is the act of pleading thecause of the client based on an understanding of their wishes.

As with the prior study in acute medicine (McGrath et. al. 2007), the doctors didnot have a language for advocacy, it is a notion exclusive to the nursing participants. InED, where the decision-making is described as medico-centric, advocacy ipso facto ne­cessitates a challenge to doctor decision-making. The ED nurses' experience with advocacyvaried depending on the democratic qualities and communication skills of the particulardoctor who had care of the consumer. Atwal and Caldwells' work points to concernsabout the nursing profession's efficacy in advocacy in the face of such medico-centrism(Atwal and Caldwell 2005). Nurses in the present ED study described a range of advocacyprocesses which varied along a continuum from non-confrontational strategies of informaldiscussions with doctors to formal and confrontational interdisciplinary discussion.Lothian (2005) refers to this as the 'dance of advocacy', where appropriate communicationis not only with consumers but, equally importantly, with other members of the healthcare team. In ED, the communication processes are recorded as supportive, non-author­itar ian and respectful of difference of opinion. In particular, senior nurses are seen asrespected for their opin ion and able to voice their advocacy concerns with openness.

The findings indicate that the support of other nurses is essential for advocacy. AsShirley (2005), it is necessary in fulfilling the moral responsibility of advocacy for nursesto speak collectively. Welchman and Griener (2005) affirm the notion of the importanceof a collective nursing responsibility and argue that both consumers and their nursessuffer unnecessarily from burdening individual nurses with the responsibility of consumeradvocacy. In short, as documented elsewhere (Vaartio et al. 2006), it is essential for ef­fective advocacy for the nurse to have the support of their team . As with the previouswork in acute medicine, the findings affirm the importance of focusing on the ethicalnature of the organisation as opposed to focusing exclusively on the individual. Thework continues to concur with Corley and associates' insights on the significance of theorganisational environment to moral distress intensity (Corley et al. 2005). As Olson(1998) points out, relationships with doctors are a major factor impacting on the hospitalethical work environment for nurses.

The findings provide insights on the difficulty of advocacy for nurses in ED. Thenotion that nurses have to overcome barriers to become effective consumer advocates isnoted elsewhere in the literature (Hanks 2007; McGrath and Walker 1999). Individualnurses reported a sense of feeling 'pushy' when they advocated, which had individualramifications for them in the team. Others indicated that their efforts to advocate forthe consumer did not necessarily translate into effective outcomes. The findings reported

ETHICAL OECISION·MAKING INAN EMERGENCY DEPARTMENT ARTIClE 16.12

here resonate with the work of McGrath and Walker (1999) in that the act of activelistening to the consumer and their family is considered easilyaccomplished but translatingthe wishes into action can be much more difficult and frustrating. In the advocacy liter­ature, the nurse 's role is described as a constant observer of the consumer's conditionwith an ethical obligation to ensure quality of care (Vaartio er al. 2006; Hyland 2002;Schroeter 2000) . However, the findings from the present study emphasise that th is is notan individual activity as support from the team and management are essential in opera­tionalising advocacy.

The negative consequence of frustration in advocacy for nurses is burn-out associatedwith a sense of not being valued by the organisation. Similar research on ethical decision­making by intensive care health professionals also indicates that medical hegemony canensure nurses' roles remain unacknowledged and devalued, with nurses unable to influencedecision-making (Coombs and Ersser 2004) . The important point for this discussion isthat such burn out is seen as having direct repercussions in terms of the quality of ethicaldecision-making on the ward : that is, the nurses posited a strong link between beingvalued by the organisation and the ability to make appropriate ethical decisions. Thenurses interviewed in Vaartio and associates' (2006) study reported professional satisfac­tion associated with advocacy, but interestingly these nurses did not experience anyproblems with respect to their professional autonomy. Thus, the indications are thatprofessional respect and autonomy are essential factors associated with satisfaction withthe ethical nursing praxis of advocacy.

A significant conceptual notion posited from the findings of the present ED study inrelat ion to the process of ethical decision-making is the idea of the 'trade off'. Throughoutthere were references to a phenomenon where a need for advocacy perceived by the nursewas either silenced or suppressed by a desire to maintain peaceful team working relation­ships. We called this priority given to 'not rocking the boat' over an advocacy responseto an ethical concern, the 'trade off'. The team was seen to work well on occasions wherethere was a shared agreement as to the best course of action . Disagreement was seen ascausing tension and thus a negative to be avoided . Maintaining the positive team spiritwas seen as important. The implication is that ethical decision-making in relation toadvocacy is directly related to how the team handles differences of opinion. There is noother mention of the notion of 'trade off' in the literature, although in the prior studyin acute medicine there was similar notion posited, that health professionals avoid takinga stand to avoid conflict (McGrath and Holewa 2006) .

The fact that many nurses struggle with feelings of powerlessness and distress inethically difficult care situations is noted throughout the literature (McSteen and Peden-

16.13 ETHICAL DECISION-MAKING IN AN EMERGENCY DEPARTMENT ARTICLE

McAlpine 2006; Astrom et al. 1995; Soderberg and Norberg 1993; Uden et al. 1995).

Without the backing of the team of nurses, advocacy can be a very isolating experience

for nurses . The participants called for nurses to embrace advocacy as an appropriateethical response to their work with consumers. A truly multi-disciplinary approach is

noted as a necessary prerequisite to integrate nursing advocacy into the system so thatnurses are not 'bystanders' but rather active participants in the ethical decision-makingprocess.

CONCLUSIONMany of the insights from the study in ED resonate with the original work in acutemedicine, especially those pertaining to the problems created by medico-centrism andlack of organisational support for the individual nurse's efforts to advocate for their

consumers. It is with confidence that the authors can state that advocacy needs to be

embraced at a professional and collegial level if nurses are to be protected against unreas­onable stress and consumers' needs are to be appropriately attended to. As Welchmanand Griener (2005) state:

Our admiration would not be diminished if henceforth we recognised

that advocacy for patients' interest is not and cannot be the sole re­

sponsibility of individual nurses .

FUNDINGThis study was supported by a collaborative Industry Grant offered by Central QueenslandUniversity and Redland Hospital.

REFERENCESAstrom, G. et. al. 1995. 'Nurses' skills in managing ethically difficult care situations: interpretation

of nurses' narratives'. Journal of Advanced Nursing 21 (6): 1073-1080.Atwal, A.; Caldwell, K. 2005. 'Do all health and social care professionals interact equally?: A study

of interactions in multidisciplinary teams in the United Kingdom'. Scandinavian Journal ofCaring Sciences 19: 268-273.

Coombs, M.; Ersser, S. 2004. 'Medical hegemony in decision-making - a barrier to interdisciplinaryworking in intensive care?' Journal of Advanced Nursing 46: 245-252.

Corley, M. et, al. 2005. 'Nurse moral distress and ethical work environment' . Nursing Ethics 12:381-390.

ETHICAL OECISION·MAKING INAN EMERGENCY OEPARTMENT AIlTlCLE 16.14

Creswell, J.W. 2003. Research Design: Qualitative, Quantitative and Mixed Method Approaches.

2nd edn. Thousand Oaks: Sage.Curtin, L. 1979 . 'The nurse as advocate : A philosophical foundation for nursing '. Advances in

Nursing Science 1 (3): 1-10.Gadow, S. 1980. 'Existential advocacy : Philosophical foundation of nursing ' . In Nursing: Images

and Ideals, edited by Spricker, S.F.; Gadow, S. New York: Springer Publishing Company.Gaylord, N.; Grace, P. 1995 . 'Nursing advocacy: An ethic of practice'. Nursing Ethics 2 (1): 11-18.Gearing, R.E. 2004 . 'Bracketing in research : a typology' . Qualitative Health Research 14 (10):

1429-1452.Giorgi, A; Giorgi, B. 2004 . 'The descriptive phenomenological psychology-calmethod'. In Qualitative

Research in Psychology: Expanding Perspectives in Methodology and Design, edited byCarnic, P. et. al. Washington , DC: American Psychological Association .

Grbich , C. 2007. Qualitative data analysis: An introduction. London : Sage.Hanks, R. 2005 . 'Sphere of nursing advocacy model' . Nursing Forum 40 (3): 75-78 .Hanks, R. 2007 . 'Barriers to nursing advocacy: a concept analysis' . Nursing Forum 42 (4): 171-177.Hewitt, J . 2002 . 'A critical review of the arguments debating the role of the nurse advocate'. journal

of Advanced Nursing 37: 339-445.Holloway, I. 2008 . A-Z ofQualitati ve Research in Healthcare. 2nd Ed. Oxford : Blackwell Publishing.Hyland, D. 2002 . 'An exploration of the relationship between patient autonomy and patient

advocacy: implications for nursing practice ' . Nursing Ethics 9: 472-483.Kohnke, M. 1982 . Advocacy: Risk and Reality. St Louis: CV Mosby C.Kvale, S. 2007. Doing Interviews. 2nd edn . Thousand Oaks: Sage.Lothian , J. 2005 . 'The dance of advocacy '. journal of Perinatal Education 14: 36-39.McGrath, A.; Walker, A. 1999 . 'Nurses' perception and experiences of advocacy'. Contemporary

Nurse 8 (3): 72-78.McGrath, P. et al. 2006. 'Patient-centred care: Qualitative findings on health professionals

understanding of ethics in acute medicine' . journal of Bioethical Inquiry 3 (3): 149-160.McGrath, P. et al. 2007. 'Nursing advocacy in an Australian multidisciplinary context: Findings

on medicocentrism'. Scandinavian journal of the Caring Sciences 20 (4): 394-402.McGrath, P.; Henderson, D. 2008a. ' '' Oh, that's a really hard question" : Australian findings on

ethical reflection in an accident and emergency ward '. HEC Forum 20 (4): 357-373.McGrath, P.; Henderson, D. 2008b. 'Resolving end of life ethical concerns : Important palliative

care pract ice development issues for acute medicine in Australia '. American journal ofHospice and Palliative Medicine 25 (3): 215-222.

McGrath, P.; Holewa, H. 2006. 'Ethical decision making in an acute medical ward : Australianfindings on dealing with conflict and tension '. Ethics and Behavior 16 (3): 233-252.

McSteen, K.; Peden-McAlpine, C. 2006 . 'The role of the ?urse as advocate in ethically difficult caresituations with dying patients' . journal of Hospice and Palliative Nursing 8 (5): 259-269.

Mitty, E. 1991. 'The nurse as advocate: Issues in LTC'. Nursing Health Care 12: 520-523.Olson, L. 1998. 'Hospital nurses' perceptions of the ethical climate of their work setting'. Image

journal of Nursing Scholarship 30: 345-349.

16.15 ETHICAL DECISIDN·MAKING INAN EMERGENCY DEPARTMENT ARllClE

Schroeter, K. 2000. 'Advocacy in perioperative nursing practice'. Association of Perioperatiue

Registered Nurses Journal 71: 1207.Shirley, N. 2005 . 'Our roots in nursing: Advocacy and activism'. Nebraska Nurse May: 3.Soderberg, A.; Norberg, A. 1993. 'Intensive care: Situations of ethical difficulty' .Journal of Advanced

Nursing 18 (12): 2008-2014.Uden, G. et al. 1995 . 'The stories of physicians, registered nurses and enrolled nurses about ethically

difficult care episodes in surgical care '. Scandinavian Journal of Caring Science 9 (4):245-253 .

Vaartio, H . et al. 2006 . 'Nursing advocacy; how is it defined by patients and nurses, what does itinvolve and how is it experienced?' Scandinavian Journal of Caring Science 20: 282-292.

Van Manen, M. 1990 . Researching lived experience. Albany: State University of New York Press.Welchman, J.;Griener, G. 2005 . 'Patient advocacy and professional associations: Individual and

collective responsibilities'. Nursing Ethics 12 (3): 296-304.

Cite this articleas: McGrath, Pam; Phillips, Emma. 'Ethical decision-making in anemergencydepartment: Findings onnursing advocacy'. Monash Bioethics Review 28 (2): pp. 16.1 to 16.16.001: 10.2104/mber0916.

ETHICAL DECISION-MAKING INAN EMERGENCY DEPARTMENT ARTICLE 16.16