Expanding Our Understanding Complex Decision-Making in Emergent, Routine and Urgent Ethically Challenging Clinical Situations

Purpose: Nurses routinely provide care to patients in ethically challenging situations. The purpose of this study was to discover and identify the continuum between conscientious objectors and designated staff in the provision of nursing care to women seeking abortions. More specifically, we sought to gain a deeper understanding of processes that nurses use when making clinical decisions in ethically challenging situations in both urgent and routine care provision using abortion as the clinical context.

Methods: Constructivist grounded theory method was used. A purposive sample of 24 nurses who currently or previously work in abortion clinics, emergency departments, labor and delivery, operating rooms and post anesthesia care units were interviewed between November, 2012 and August, 2013. Questions were designed to examine and explore the cognitive, emotional, and behavioral processes associated with how nurses make decisions to care for women needing and seeking abortions.

 Results: Nurses develop and use multifaceted, real-time calculi in several dimensions when making decisions about their participation in emergent, routine, or urgent abortion care provision. Additionally, nurses make a clear distinction between knowing how versus know that, meaning knowing how to take care of women needing abortions doesn't always result in provision of care and knowing that (i.e., the circumstances and back story of why women need this care) is a better predictor of its provision. Parameters of the nurse-patient relationship are different than medicine in the abortion context as nurses make clear distinctions between women and patients and these distinctions impacts the taxing between the personal and professional factors that influence calculus formation. Finally, the role of others, broadly defined in the abortion context creates a complex yet integrated variable to be considered in the decisions impacting care provision.

 Conclusion: This study provides a grounded theory of calculus formation that further develops the science of real-time ethical decision-making in ethically challenging situations. These data expand our understanding of the multitude of factors that impact and influence nurse decision-making.  Effective strategies exist that facilitate tuning of individual nurses’ calculus formation particularly infrastructural, institutional and other external factors that are essential components of the environment of care.