Erb, 1995).
The first stage of the Pre-conventional level is the Right of literal obedience to
rules and authority, avoiding punishment, and not doing physical harm (Kohlberg,1927).
This stage takes an egocentric point of view. A person at this stage does not recognize
the interests of others. They do not relate two points of view. Instead, they value their
own beliefs. Actions are judged in terms of physical consequences rather than in terms
of psychological interests of others (Kohlberg, 1927). For instance, a nurse follows a
physician’s orders so as not to be fired, although many nurses may have
conflicting beliefs it is their duty to carry out DNR orders. Many statutes provide
immunity to health care providers who do. Failing to honor an DNR order could lead to
a battery suit by the patient or his family, and disciplinary action by the Board of
Nursing (Sloan, 1996). Individuals function in order to avoid punishment. Rules are
sacred and unchangeable, and those who violate rules must be punished according to the
magnitude of their offenses (Shultz, 1997).
Health care as a profession involves far more ethical principles than perhaps any
other profession. Nurses, as well as other health care professionals with a principle-
centered life and practice, create an internal structure that will help them consistently
meet ethical obligations to themselves, patients, families, and communities. Developing
a central set of Principles, encourages nurses to apply the same set of ethics to
themselves as well as to their patient (Moss, 1995).
Jezewski (1994) conducted a study to describe the conflict that occurs during the
process of consenting to do-not-resuscitate status and the strategies used by critical
care nurses to attempt and prevent, minimize, and/or resolve these conflicts. His study
consisted of a grounded theory design. Twenty-two critical care nurses practicing in
upstate New York in urban and rural, profit and nonprofit hospitals were involved in the
study. Of the 22 participants, 21 were female and 1 was a male. The age range was 26-53
years old, with a mean of 34 (+ or – 6 years). Years in practice ranged from 4-31 years.
Semi-structured, in-depth interviews were used to collect data. The interview schedule
consisted of open-ended questions and were formulated to elicit nurses’ experiences in
the context of interacting with patients and family members during the process of their
deciding whether to consent to a DNR status. The data was analyzed with the continuous
comparative method of grounded theory. The results show that conflict occurred during
the process of consenting to DNR status. Two major categories of conflict were
intrapersonal (inner conflict in coming to terms with DNR-status decision) and
interpersonal (conflict that took place between individuals involved in consenting to a
DNR status). Intrapersonal conflict, for the nurses occurred while determining the
appropriateness of DNR order for their patients and coming to terms with the meaning
of DNR status. Nurses had to come to terms that a DNR order was appropriate or
inappropriate for the patient. To do this, the nurse assessed the patient’s physical status
in conjunction with quality of life issues, conferred with other health care professionals,
and talked with the patient and/or family. It was important for the nurses to personally
resolve any conflict about the appropriateness before they could optimally assist patients
and families with the decision to consent to DNR status. Interpersonal conflict occurred
between family members, patients, and staff. Nurses descriptions of their role were
reflective of a culture broker framework incorporating advocacy, negotiation, meditation,
and sensitivity to patient?s and family?s needs. They would talk with family members to
try to understand their feelings about consenting to a DNR status. The nurses
emphasized the importance of allowing time for family members to come to terms with
the patient’s status and the meaning of DNR for themselves individually and as a group
(Jezewski, 1994).
Attitudes, values, and ethics set the stage for managed care nursing (Salladay,
1997). Ajzen and Fishbein(1980) theorized that human beings base their actions on
rational, systematic use of information; persons consider the implications of their actions
before they decide to engage in a given behavior. Attitudes are defined as the persons
evaluation of the positive or negative effects of the outcomes of specific behaviors or
actions taken. Whereas, Behavioral intention is the reported degree of likelihood that the
nurse will perform a certain action (Ajzen & Fishbein, 1980).
Nurses must decide what their own moral actions ought to be in a situation
concerning a DNR order. Because of the special nature of the nurse-client relationship,
they must support and sustain clients and families who are facing difficult moral
decisions. On the other hand, nurses must also support clients and families who are
living out the decisions made for and about them by others, or themselves. Nurses can
make better moral decisions and have a positive attitude to any given situation by
thinking in advance about their beliefs and values (Moss, 1995).
Schaefer and Tittle (1994) conducted a study to explore the attitudes and
perceptions of registered nurses (RNs) and physicians (MDs) regarding the care of
patients with do-not-resuscitate (DNR) orders in the intensive care units (ICU).
Structured interviews were conducted with twenty RNs and MDs from the ICUs of
twenty-five Veterans Administration Hospitals. The questionnaire included four
hypothetical cases which tested a statement as to who would best support the autonomy
of the patient in making a DNR decision: (a) when the patient is incompetent, (b) when
the patient is not competent and a close relationship exists with the family, (c) when the
patient is not competent, has no close relationship with family but a therapeutic
relationship exists between the physician and the patient, and (d) when the patient is not
competent, has no close relationship with the family but a therapeutic relationship exists
between the nurse and the patient. A total of 226 (45.2%) questionnaires were received;
160 (70.8%) from the RNs and 66 (29.2%) from MDs. The mean age of RNs was 38.4
with a range of 22-58. The mean age of the MDs was 42.4 with a range of 27-76. The
RNs and MDs did not agree who would best support patient autonomy in any of the four
cases (p