The Relationship between the Degree of the Forensic Nursing Capacity, Ethical Dilemma and Ethical Decision-Making Confidence
Perceived by Nurses: For Small and Medium Hospital Nurses
Mi-Ran Kim1, Jae-Woo Oh*2
1, *2Department of Nursing,Konyang University, 158, Gwanjeodong-ro, Seo-gu, Daejeon, 35365, South Korea
Abstract
This research was attempted to provide basic data for developing forensic nursing education programs by confirming the degree of the forensic nursing capacity, ethical dilemma and ethical decision-making confidence recognized by nurses at small and medium hospitals.Data collection was conducted from April 30 to May 10, 2020 for 120 nurses in small and medium hospitals. The collected data were analyzed using the SPSS 20.0 program.As a result, the low age and forensic nursing capacity of nurses showed the influence on the ethical decision-making confidence, and the explanation power for the ethical decision-making confidence was 32.4%. It is thought that it is necessary to arrange the measures and develop educational programs to improve the capacity, including the forensic nursing knowledge for new nurses.
Keywords: Nurse, forensic nursing competency, ethical dilemma, ethical decision-making Confidence, Small and Medium Hospital
*Corresponding Author : Name : Jae-Woo Oh
Email : [email protected] Contact : +82 10 9078 8579 Fax :042 600 8555
Date of Submission : 2020. 10. 02
Introduction
With the opening of the legal market, and rapid economic growth, many changes, that is, social damages such as traffic and safety accidents increase as society is industrialized and informatized. Violent crimes, sexual violence, and child and senior abuse, along with the collapse of traditional families, happen to the socially disadvantaged. In addition, medical people
are increasingly exposed to patients in situations related to such incidents, accidents, and crimes.
In particular, their obligation to report crimes against the socially disadvantaged are emphasized by the government through medical and related special laws(Korea Ministry of Government Legislation , 2014) . Because of trial-centeredness, the national jury system, and evidence-based trials, the forensic nursing role is required in many areas(JeongOungSeok, 2007). It is emphasized that the role of nurses for physical and psychological care as well as the role of forensic nursing role for recognizing, collecting and preserving evidence is necessary(Emergency Nursing Association, 2011). In addition, in order to improve the rights consciousness in line with the social problems, and changes and demands in the judicial systems, there is a need for nurses to know the conceptual difference on the terms of abuse, neglect, physical and sexual violence, intentional trauma and unintentional accidents, etc. apart from the diagnosis and planning of nursing practices and to have critical thinking for the decision-making needed in practice. A new interpretation of nursing and the practice of a role in forensic medicine and forensic nursing where health care and justice work together to find a solution are required(Lynch, 2006). For example, the patients who visit hospitals for appropriate treatment and care related to trauma and violence are not only the victims of crimes, but also potential prisoners or convicted felonies. For this reason, investigators visiting hospitals demand forensic advice from nurses and physicians in order to accurately document the degree of injury for patients and obtain relevant evidence. In fact, they conduct physical inspection and tests, transmit or store the relevant blood, tissues, etc.
to the examination room, and record the results of the patients(Lynch, 1991). However, while conducting treatment and nursing activities for patients with such legal problems, medical people who lack forensic medicine and forensic nursing capacity sometimes expose patients to risk(McGillivary,2005). In particular, biological evidence that is likely to be lost or contaminated over time can lead to incorrect judgment in the trial process by mishandling and overlooking evidence, because the nurse has no knowledge of forensic medicine or does not follow forensic guidelines, which makes it impossible to perform normal tasks by physically and mentally damaging not only the patients, but also the nurses(Kelli, 2008). Thus, the evidence for reconstruction of the case, proof of crime, and proof of innocence may disappear or be destroyed during trauma treatment, and the role of the nurse in the discovery and management of forensic cases is important( Sullivan , 2006).
Sullivan(2006), who argued that nurses should have the basic capacity to prove legal facts in a hospital environment, and that they should be able to express forensic nursing knowledge and skills in addition to existing nursing capacity, presented the forensic nursing capacity of clinical nurses by classifying it into knowledge and skills. Thus, a nurse should continue to provide the
forensic nursing and maintain the continuity of evidence, which requires nurses in various fields dealing with trauma patients, such as emergency rooms, outpatients, wards, intensive care units, operating rooms, etc. to acquire the knowledge and skills of forensic nursing which are essential for practice, and to have a professional attitude(Kim Yong Soon et al., 2011). Ethical dilemma refers to a situation in which a decision must be made by choosing in conflicts between the ethical problems that seem to be impossible to solve satisfactorily in a nursing field, and one of two or more ethical problems that are equally unsatisfactory. It is reported that the situations encountered in nursing practice are role limitation, difficulty in judgment, self-defense attitudes, difficulties in human relations, inextricable practices, problems due to lack of adequate nursing staff, conflicts due to lack of nursing knowledge and experience when attempting the active treatment in patients who are unable to recover, excessive nursing work, and when there is no hope for patient's life extension(Kim Yong Soon et al., 2011). Ethical dilemma usually arises from the confusion of values or beliefs about the best behaviour, and choice. The ethical decision-making in the ethical dilemma situation should be based on the values and ethical knowledge of each nurse, and systematic and logical thinking should be the basis of it( Sim OkJoo, 2002). The ethical decision-making confidence is the identification of value confusion, recognition of expectations, recognition of readiness for knowledge and skills, and the ability to do the right thing in a given situation, and the subjective recognition of one's abilities, which can have a positive effect on the ethical decision-making in the ethical dilemma situation.
In other words, nurses need to have a high confidence in decision-making so that they can recognize the ethical dilemma in the various situations which they face in their practice and perform the ethical decision-making based on the forensic nursing capacity. In Korea, however, the Department of Forensic Nursing at the Graduate School of Investigative Science was established in the 2000s. The history of forensic nursing is short, and the research and awareness of it are still insufficient, indicating a high lack of forensic nursing knowledge among nurses.
Therefore, this research was attempted to provide basic data for developing forensic nursing education programs by confirming the degree of the forensic nursing capacity, ethical dilemma and ethical decision-making confidence recognized by nurses at small and medium hospitals.
Materials and Methods Study Design
This is a descriptive survey research to identify the relationship between the degree of the forensic nursing capacity, ethical dilemma and ethical decision-making confidence which nurses perceive Study Subjects
This study was conducted for 120 nurses working at small and medium-sized hospitals located in
K City.
Research Tools
The Degree of Forensic Nursing Capacity
The tool for measuring the degree of the forensic nursing capacity of nurses was developed by Jo Na-young(2017), which consisted of eight sub-areas(53 questions in total), such as nursing practice, information delivery, critical thinking, care and evidence management, active information collection, professional development, and knowledge integration. In the 4-point Likert scale, the higher the score, the higher the degree of forensic nursing capacity. Cronbach's a
= .96 in the study at the time of tool development, however, Cronbach's a= .98 in this study.
Ethical Dilemma
In order to measure the ethical dilemma, it was measured using the tool that Kim Ji-Hye(2012) modified and supplemented with the tool developed by Han Sung-Sook(1992). It consisted of 4 sub-areas(34 questions in total), including human life areas(7 questions), subject area(6 questions), professional work area(14 questions), and collaborator area(7 questions). Each question was measured with the 4-point Likert scale, which is “Not Very”(1 point) to “Very Much”(4 points), meaning the higher the score, the higher the ethical dilemma. In this study, Cronbach's a = .94.
Ethical Decision-Making Confidence
The contents of the ethical decision-confidence were measured using the tool that Kim Ji- hye(2012) modified and supplemented with the tool of perceived ethical confidence scale which Sulmasy et al.,(1990) developed. The questionnaire, which consisted of 9 questions in total, used the 5-point Likert scale(from “Not at all”(1 point) to “Very yes”(5 points), indicating the higher the score, the higher the ethical dilemma. In this study, Cronbach's a = .91.
Data Collection
The data was collected from Apr 30, 2020 and to May 10, 2020. As for the method of data collection, the purpose and method of the study were explained to the head of the hospital department, the questionnaires were distributed to the subjects who agreed to participate in the study, and the cautions and response methods were explained to them by the researcher. Before collecting the data, the subjects were explained about the purpose of the study, personal confidentiality, and that the questionnaire wouldn’t be used for purposes other than research, according to the research ethics.
Data Analysis
The collected data were analyzed using SPSS/Win 20.0 Program. The general characteristics of the subjects were done with real numbers and percentages, the degree of the forensic nursing capacity recognized by nurses was done with the average and standard deviation, and the
correlation between variables was done with the Pearson correlation coefficient, and the factors affecting the ethical decision-making confidence of the subjects were done with regression analysis.
Results and Discussion Results
General Characteristics of Subjects
As a result of examining the general characteristics of the subjects, it is like Table 1. 108 people were women(91.5%) in gender, 68 people were 20-29 years in age(57.6%), 71 people were unmarried in marital state(60.2%), 71 people graduated from a university in academic background(60.1%), 35 people worked at the surgical ward(29.6%) in duty wards, and 30 people had clinical experience of more than 5 to less than 10 years(25.4%), which was highest. For the question of whether they knew about the forensic nurse, 72 people(61%) answered that they generally didn’t know, which was highest, and for the question of the experience of forensic nursing education and that of the need for forensic nursing education, 94 people answered
“No”(79.7%), and 108 people did “Yes”(91.5%), respectively< Table 1>.
Table 1. General Characteristics of Subjects N=118
Variables Categories No(%) Mean±SD
Gender
Female 108(91.5)
Male 10(8.52)
Age
20~29 years 68(57.6)
30.29(6.273)
30~39 years 39(33.0)
40 years or more 11(9.4)
Marital State
Married 47(39.8)
Single 71(60.2)
Academic Background
College Graduate 44(37.2)
University Graduate 71(60.1) Graduate School or Higher 3(2.7)
Duty Wards
Internal Medicine Ward 14(11.8)
Surgical Ward 35(29.6)
Intensive Treatment Room 10(8.5)
Emergency Room 15(12.7)
Operating Room 17(14.4)
Others 27(23.0)
Clinical Experience
Less than 3 years 36(30.5)
3 ~ 5 years 25(21.2)
5 ~ 10 years 30(25.4)
10 ~ 15 years 16(13.6)
15 years or more 11(9.3)
Recognition of Forensic Nurses
Knowing Well 8(6.8)
Knowing 24(20.3)
Generally Not Knowing 72(61.0) Not Knowing At all 14(11.9) Experience of Forensic Nursing
Education Completion
Yes 24(20.3)
No 94(79.7)
Necessity of Forensic Nursing Education
Yes 108(91.5)
No 10(8.5)
Proper Education Type
Supplementary Education 72(61.0) Preceptor Education 8(6.8)
Job Training 29(24.5)
Graduate Education 6(5.1)
Others 3(2.6)
Degree of Variables Recognized By Subjects
The degree of the forensic nursing capacity recognized by the subjects was an average rating of 3.2 out of 4, the ethical dilemma was an average rating of 3.0 out of 4, and the ethical decision- making confidence was an average rating of 3.7 out of 5, which were above normal< Table 2>.
Table 2. Degree of Variables Recognized By Subjects
Variables Mean±SD Range
Forensic Nursing Capacity 3.289± 0.373 1-4
Ethical Dilemma 3.019± 0.388 1-4
Ethical Decision Making Confidence 3.707± 0.544 1-5
Correlation between Variables
As a result of analyzing the correlation between the forensic nursing capacity, ethical dilemma, and ethical decision-making confidence of the subjects, the forensic nursing capacity showed a positive correlation with the ethical decision-making confidence(r = .518, p <.001)< Table 3>.
Table 3. Correlation between Variables
Variables Forensic Nursing
Capacityr(p)
Ethical Dilemma
Ethical Decision- Making Confidence Forensic Nursing Capacity 1
Ethical Dilemma .064 1
Ethical Decision-Making Confidence .518*** .158 1
Factors Affecting the Ethical Decision-Making Confidence of Subjects
As a result of analyzing the factors that affect the ethical decision-making confidence of the subjects, among the general characteristics of the subjects, the low age and forensic nursing capacity of nurses showed the influence on the ethical decision-making confidence, and the explanation power for the ethical decision-making confidence was 32.4%< Table 4>.
Table 4. Factors Affecting the Ethical Decision-Making Confidence of Subjects
Variables B SE β R2 Adj. R2 t p
Constant 1.404 .364 3.860
Forensic Nursing Capacity .748 .109 .512 .269 .263 6.877 .000
Low Age of Nurses
(20~29세) -.282 .081 -.259 .335 .324 -3.474 .000
R2=.335, Adj. R2=.324, F=30.280, p<.001
Discussion
The relationship between the forensic nursing capacity, ethical dilemma, and ethical decision- making confidence of small and medium hospital nurses was examined, and the effect of the forensic nursing capacity and the ethical dilemma on the ethical decision-making confidence was identified. The major results are discussed as follows.
The degree of the forensic nursing capacity recognized by the subjects was average rating of 3.2 out of 4. As there are no prior studies that measured the forensic capacity of nurses, direct comparison with them is difficult. However, it is considered that this result indicates the increase in the forensic nursing capacity in many areas due to trial-centeredness, national jury system, and evidence-based trials in the medical field, along with many changes due to the opening of the legal market and rapid economic growth. The ethical dilemma recognized by the subjects was an average rating of 3.0 out of 4, which was similar to the research result of Kim Ji-Hye(2008). This result was higher than that of the research of Ki Eun–Hee(2008).for the nurses in Seoul(2.15 points), which identified that the ethical dilemma situation increased according to the rapidly
changing medical environment. The ethical decision-making confidence recognized by the subjects was average rating of 3.7, which was higher than that(3.4 points) of Kim Ji-Hye(2012).It is thought that in recent medical conditions that demand the specialization of health services and the improvement of quality of nursing, due to the changes in new disease patterns, advances in medical technology, and the improvement of awareness of consumer rights, the nurses are required to take the responsibility of decision- making and decision as a professional in the situation where the ethical dilemma which can affect the life quality of the subjects happens, which led to this result.
As a result of analyzing the correlation between the forensic nursing capacity, ethical dilemma, and ethical decision-making confidence of the subjects, the forensic nursing capacity showed a positive correlation with the ethical decision-making confidence(r=.518, p<.001).That is, it could be identified that the higher the forensic nursing capacity, the higher the ethical decision-making confidence. Sullivan(2006) insisted that nurses should have the basic capacity to prove legal facts in the hospital environment, and should be able to express forensic nursing knowledge and skills in addition to the existing nursing capacity to do so. Lynch(2006) said that the new interpretation and the practice of a role of nursing in the field, such as forensic science and forensic nursing, where medical and justice work together to find solutions for improving citizens' rights awareness in line with the social problems, changes and demands in the judicial system, are required to nurses in Korea.As a result, in the ethical dilemma situation that can affect the life quality of the subjects, it is considered that in order to adapt to changes in the current medical environment that require nurses to take responsibility for decision- making and decisions as a professional, they need to improve the forensic nursing capacity.
As a result of analyzing the factors affecting the ethical decision-making confidence of the subjects, among the general characteristics of the subjects, the low age and forensic nursing capacity of nurses showed an influence on the ethical decision-making confidence, and the explanatory power for the ethical decision-making confidence was 32.4%. Nurses should have the forensic nursing capacity to deal with the social and legal changes in providing the quality nursing for the victims and perpetrators, and families and communities related to trauma, injury, accidents, abuse, neglect, exploitation, and all types of violent crimes. Shim Ok-Ju(2002) said that nurses are heavily influenced by their beliefs and values in ethical decision-making, so it is thought that the results of this study suggest that it is necessary to develop and support strategy classes and educational programs focused on improving the ethical decision-making confidence of nurses.
Based on the results of this study, as it was identified that the lower the age of nurses, the higher the forensic nursing capacity, the higher the ethical decision-making confidence of nurses, it is
thought that it is necessary to arrange the measures and develop educational programs to improve the capacity, including the forensic nursing knowledge for new nurses.
Conclusion
Changes in the medical environment where life science and medical technology are highly developed and where patients’ rights are very important require nurses to have decision-making ability and responsibility as a professional. Therefore, it is considered that in order to improve the ability with which a nurse can perform decision-making, showing the forensic nursing capacity in the ethical dilemma situation which is experienced in the nursing field, it is necessary to arrange the institution and to develop the systematic education program. In the future, it is suggested that based on the results of this study that the lower the age, the higher the ethical decision-making confidence, the nursing curriculum should be revised to improve the forensic nursing capacity and the ethical decision-making confidence.
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