Rapid changes in health care, especially technology, have created a myriad of dilemmas that professional nurses must face in everyday practice when caring for patients ranging from the 12-ounce premature infant to the 80-year-old undergoing coronary artery bypass surgery. When these changes are coupled with organizational initiatives such as patient care delivery redesign and cost containment pressures that also produce ethical dilemmas, it is critical to patient outcomes that nurses engage in the highest standards of ethical practice. Ketefian's meta-analysis of the relationship of education and moral reasoning to ethical practice summarized the present state of knowledge gained from 12 quantitative studies conducted between 1987 and 1997.
Although Ketefian claims that research related to nurses' ethical practice is maturing, it is disconcerting to note that this meta-analysis including studies through 1997 continues to be plagued by limitations identified in three previous comprehensive literature reviews spanning the years from 1968-1994 (Cassidy, 1996; Gortner, 1985; Ketefian, 1989). A major issue that constrains future work related to nurses' ethical practice is the fact that researchers have not consistently analyzed or defined the construct in any scientific manner.
What is meant by the construct, "ethical practice?" Ketefian (1989) defines ethical practice as the "decisions made and actions taken in ethical dilemma situations" (p. 174). Nurses' ethical practice is a complex phenomenon that is embedded within a specific organizational context and related to specific patient care situations. Nurses' ethical practice is not an independent activity but is a collaborative one that involves patients, families, and other members of the health care team. It is clear that the research related to nurses' ethical practice has been limited in its dimensions.
Ketefian (1989) suggested that Rest's (1984) four-component model of moral behavior might explain discrepancies in findings related to the relationship between moral reasoning and ethical behavior. Cassidy (1996) also used Rest's model as a framework for analyzing research in nursing ethics from 1987-1994. She conceptualized nurses' ethical practice as "moral competency" that encompasses Rest's four components. Cassidy (1996) noted that more work has been done with the cognitive and affective aspects of nurses' ethical practice than with intention or behavioral aspects.
Rest's model has the potential to provide a framework for future research related to nurses' ethical practice. Although he used the term moral behavior, most would agree that it could be used interchangeably with ethical practice for those in a practice profession.
Rest (1984) conceptualized moral behavior as the outcome of four processes or components that interact with one another and collectively constitute moral behavior. The first component consists of interpreting a situation and recognizing that an ethical dilemma is present that requires some action to resolve. This process has been called moral awareness or moral sensitivity. The second component involves making decisions regarding what actions ought to be taken in any given situation. This component is synonymous with moral reasoning or moral judgment. The third component involves the decision to carry out the ideal action regardless of other competing values. Rest refers to this as moral motivation. The fourth component is implementing the plan of action and persevering despite difficulties or constraints that may be present in the situation. This component is labeled moral character. Unethical behavior can occur when any of the four processes are disrupted by other internal or external influences (Rest, 1984).
One might also ask how nurses' ethical practice differs from nursing practice. Standards of Clinical Nursing Practice (American Nurses Association [ANA], 1998) identify processes that define …