NURSING STUDENTS’ EXPERIENCE

OF ETHICAL PROBLEMS AND USE

OF ETHICAL DECISION-MAKING
MODELS
Miriam E Cameron, Marjorie Schaffer and Hyeoun-Ae Park

Key words: conflict; ethical decision-making models; nursing education; nursing

ethics

Using a conceptual framework and method combining ethical enquiry and phenome-
nology, we asked 73 senior baccalaureate nursing students to answer two questions: (1)
What is nursing students’ experience of an ethical problem involving nursing practice?
and (2) What is nursing students’ experience of using an ethical decision-making model?
Each student described one ethical problem, from which emerged five content categories,
the largest being that involving health professionals (44%). The basic nature of the ethi-
cal problems consisted of the nursing students’ experience of conflict, resolution and
rationale; 85% of the students stated that using an ethical decision-making model was
helpful. Although additional research is needed, these findings have important implica-
tions for nursing ethics education and practice.

Introduction
To the question: ‘What situation involving nursing practice has caused you the
most conflict about the right thing to do?’, a senior baccalaureate nursing student
replied:
I knew what they [nursing staff] were doing was wrong, and I wanted them to stop,
but I was too scared to tell anyone. The people [nursing staff] who were abusing him
[resident] the most were employees who had been working at the nursing home for
years and who had lots of authority. I feared what they [nursing staff] would do . . . I
let the abuse happen . . . I never did resolve the conflict.
This student described an ethical problem, a situation involving conflict about
the right thing to do, but she was unable to resolve the conflict effectively.
Although stressful ethical problems confront nursing students, research is lack-

Address for correspondence: Miriam E Cameron, 220 Dakota Avenue South, Minneapolis,
MN 55416-1016, USA. E-mail: camer008@tc.umn.edu

Nursing Ethics 2001 8 (5) 0969-7330(01)NE453OA © 2001 Arnold

 Ethical problems and decision-making models 433
ing about the content and basic nature of their experience regarding ethical prob-
lems.
Han and Ahn1 identified four areas of content regarding nursing students’
ethical problems: respect for life; nurses and clients; nurses and professional
practice; and nurses and coworkers. The most frequent conflicts concerned not
telling the truth to clients, and families giving up on persons who could not be
cured. This research did not address the basic nature of nursing students’ ethical
problems. The study was conducted in Korea, so the results may not be pertinent
to nursing students in the West. Research has been published about graduate
nurses’ ethical problems involving cancer, lying, neonatal care, euthanasia,
assisted suicide and end of life care.2–6 Studies have been conducted on the
ethical development and reasoning of both nursing students and nurses.7–11 These
studies do not indicate if nursing students and nurses experience similar ethical
problems.
Swider and colleagues12 identified three reasons for the stress of nursing stu-
dents’ ethical problems: conflicting responsibilities and loyalties, confusion about
how to respond, and resolving conflict in individual ways. They concluded that
nursing students would feel less stress and develop better resolutions by
analysing conflict within an informed conceptual framework. Some nurse educa-
tors responded by teaching ethical decision-making models, although research is
lacking about their usefulness. As nursing ethics educators, we want to base our
teaching on research and philosophy. Thus, we conducted a study to answer two
questions: (1) What is nursing students’ experience of an ethical problem involv-
ing nursing practice? and (2) What is nursing students’ experience of using an
ethical decision-making model? The purpose of this article is to describe the study
and its implications for nursing research, ethics education, and practice.

Background
Two previous studies investigated both the content and basic nature of individ-
uals’ experience regarding ethical problems: 'Ethical problems experienced by per-
sons with AIDS’13,14 and ‘Ethical problems experienced by elders‘.15 The
conceptual framework and method of both studies combined ethical enquiry and
phenomenology. The ethical enquiry consisted of descriptive ethics (examination
of an ethical problem), normative ethics, (the right way to resolve the conflict and
rationale for the action), and meta-ethics (meanings of ethical terms used, such
as ‘good person’).16 The phenomenological aspect (the study of phenomena or
lived experience) was based on work by Oiler17 and by Spiegelberg.18 Rather than
impose a framework, this kind of phenomenology elicits participants’ perspec-
tives (experience of an ethical problem) and allows essences (content and basic
nature) to emerge. Essences unify apparent diversity and describe a core of mean-
ing.
In the first study, 30 persons with AIDS and persons significant to them
answered the question: ‘What situation involving AIDS has caused you the most
conflict about the right thing to do?’ The second study consisted of asking 30
older people and their families: ‘What situation involving your/your older rela-
tive’s health has caused you the most conflict about the right thing to do?’ The

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434 ME Cameron et al.
participants reflected the ethnic and social diversity of the USA. An example of
content was conflict about death, and the basic nature consisted of conflict about
the right thing to do, the resolution of the conflict, and the rationale for the res-
olution. Ethical listening proved to be a therapeutic intervention. This kind of lis-
tening means to focus actively and selectively on someone’s conflict, which can
help to resolve it.
In a serendipitous finding, the participants resolved their conflict in a manner
more like virtue ethics than principlism or ethical caring, which are three well-
known normative ethical theories. Virtue ethics, based on teachings by Aristotle19
and by Plato,20,21 holds that, to be happy, we must behave virtuously. Principlism
uses abstract ethical principles, such as justice, to resolve conflict.22,23 Ethical car-
ing emphasizes our interconnectedness.24–28 From these studies emerged an eth-
ical decision-making model: ‘value, be, do: guidelines for resolving ethical
conflict’.29 The model’s three questions are similar in content to Aristotle’s19 con-
templative reasoning, moral virtue and calculative reasoning, and they integrate
virtue ethics, principlism and ethical caring, suggesting a more comprehensive
theory of ethics.30,31
While these studies were being conducted, Cameron and Schaffer32 developed
‘a model for teaching nursing ethics,’ which has been used to teach baccalaure-
ate nursing students since 1988. In the three-part model, the faculty integrates
ethics throughout the curriculum, students take a philosophy course in ethical
theory, and they attend a four-hour nursing ethics seminar as seniors. During the
seminar, a nurse ethicist teaches five ethical decision-making models, as listed in
Appendix 1. One model, entitled ‘value, be, do: guidelines for resolving ethical
conflict’,29 is described above. Three models based on principlism are: ‘action
guides of Beauchamp and Childress’,16 ‘Frankena’s mixed deontological theory of
obligation’,30 and ‘Thiroux’s universal ethical principles’.33 Cameron29 developed
the fifth model, the ‘caring and justice ethical decision-making model’ for stu-
dents who view principlism as too abstract and lacking in caring.

Conceptual framework and method

The conceptual framework and method were similar to those of the studies on
AIDS patients13,14 and older people15 except that this research collected data
through essays, not interviews. We conducted a pilot study to adapt the method
to
this research. Appendix 2 describes the method. The participants were 73
baccalaureate nursing students (67 women, six men) who attended the nursing
ethics seminar at a midwestern college in the USA. Their ages ranged from 20 to
36 years (mean 24). We followed ethical standards for the treatment of human
subjects, the college Human Subjects Committee approved the research, and
the students signed consent forms. Because the essays were assigned to evaluate
application of the 'nursing ethics seminar content, coercion was avoided by grad-
ing and returning the essays before the students agreed to participate in the study.
The students received these written instructions:
At the nursing ethics seminar, hand in an essay consisting of one or two typed or two
or three handwritten pages in which you answer the question: ‘What situation involv-

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 Ethical problems and decision-making models 435
ing nursing practice has caused you the most conflict about the right thing to do?’
Describe and examine why you felt conflict or are feeling conflict, your resolution of
the conflict, and the rationale for your resolution. After the nursing ethics seminar, write
a second essay consisting of three typed or four handwritten pages in which you resolve
your ethical conflict from the first essay by using an ethical decision-making model pre-
sented during the seminar. Explain how the model does or does not make a difference
to your resolution and rationale, and why.
To assure scientific adequacy, we planned the research with nursing students,
faculty members, and ethicists. We assigned each student a code number, removed
identifying information, used students’ direct quotes, and reported the data in
aggregate. Two authors each analysed half the essays, validated the other half,
and analysed across essays to establish common elements. The third author val-
idated the analysis of each essay and across essays. Two independent assessors
validated the final results. A limitation was that we could not ask for more data
after the students had donated their essays to the research. For example, many
students wrote about ethical problems involving nursing staff, but did not nec-
essarily identify the educational level of nursing staff.

Results
The content of nursing students’ experience of ethical problems
The 73 students each described one ethical problem they had experienced as a
nursing student or a nursing assistant. Table 1 sets out the five content categories
that emerged and the percentage of ethical problems in each category. The
following section reports a representative ethical problem stated by a student in
each content category and describes the essence of the category.

Ethical problems involving health professionals

This category includes nursing staff (registered nurses, licensed practical nurses,
nursing assistants) and physicians. Under nursing staff, six subcategories
emerged:
• Medications and treatments: ‘What is the right thing to do when you see

Table 1 Content categories and percentages of ethical problems

Ethical problem %

Health professionals
Nursing staff 40
Physicians 4
Quality of life/dying and death 26
Disagreement with a client’s behavior 18
Persons with HIV/AIDS and other contagious diseases 8
Managed care 4
Total 100

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436 ME Cameron et al.
another nurse taking a short cut that could potentially be harmful to a client?’
The students felt conflict when nurses gave medications and treatments
inappropriately:
The most disturbing thing I have experienced in nursing practice is how people do not
follow standard procedures and protocols. I have seen this at almost every clinical site,
and it seems to be with many nurses. It is very unnerving for me to see nurses taking
short cuts in their work and risking the client’s health. Seeing fellow professionals act-
ing as nonprofessionals angers me.

• Quality care: ‘What should I do when clients are not receiving the care they
need and the staff are not properly trained?’ The students wondered how to
respond to nursing staff who gave poor care.
I began to see many unsafe practices going on. As a new employee I did not feel com-
fortable pointing out errors and I tried to fit in . . . I felt that I should do something
about the safety of the clients, but I didn’t know what.

• Harmful behaviour: ‘Should I report a coworker/friend’s inappropriate or

potentially harmful actions toward a patient?’ The students questioned the
right way to deal with nursing staff who acted in harmful ways.
If I reported her, I would risk losing our friendship but, if I didn’t, she could hurt some-
one. I was confused because I knew if I reported her, our workplace would be filled
with tension and anger due to the fact that I would be breaking trust.

• Force-feeding: ‘Should I follow the instructions of nursing staff and force-feed

a client to eat, or let her starve herself?’
• Client confidentiality: ‘What should I do when my preceptor and I have vio-
lated the confidentiality of a client?’
• Caught in between: ‘What should I do when I feel as if I’m being asked to
take sides between a nurse and a client?’ The students felt caught between
clients and staff who force-fed elderly people, created conflict, and jeopardized
confidentiality.

I totally felt in the middle of everything Both parties were valid in what they said. I
felt like I was being asked to choose sides. The whole situation really made me uncom-
fortable.
Regarding physicians, a student asked, ‘What should I do when I feel the doc-
tors have put me in a situation where I have to lie to a patient?’ Another student
wrote about a physician’s unprofessional behaviour:
I observed a female doctor yelling angrily at a fellow student of mine, then throwing
the chart on the floor with all its content papers flying about loose from the binder.
The student seemed in shock, almost paralysed in fear, without reacting to the incident.
The doctor raged at the student for taking her ‘precious time’ with meaningless tasks.
To us, unprofessionalism was an ethical issue, especially coming from an authority
figure with vast knowledge and experience.

Ethical problems involving quality of life/death and dying

‘Who has the right to say who should live or die?’ The students questioned how
to treat clients who could not make their own decisions:

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 Ethical problems and decision-making models 437
The nurse said he [the patient] had minimal brain waves and all his movements were
reflexes. His wife claimed he was making meaningful gestures. I did not know who to
believe. Do I inform him about everything I am doing? It was hard talking to someone
who doesn’t respond. I struggled with the nurses’ ethics about talking about him when
he was right there. I also struggled with prolonging grief. It’s not right to hold on to
someone because it’s too hard to let them die.

Ethical problems involving disagreement with clients’ behaviour

‘What should I do when my client’s lifestyle does not agree with my values?’ The
students wrote about uncomfortable situations, such as a man who sold pornog-
raphy and a pregnant woman who might be using drugs.
One day I started to wonder if over time I would start to neglect my moral beliefs and
accept their lifestyle. It is not my place as a nurse to impose my moral beliefs on peo-
ple, but if I was exposed to these lifestyles day after day, I would need to address their
situation, or I would feel like I was compromising my beliefs.

Ethical problems involving persons with HIV/AIDS and other contagious diseases
‘Do nurses have the right to know if patients are infected with AIDS or another
contagious disease?’ The students worried about being infected, as one student
wrote:
We do so much for people in the hospital. We provide physical care, as well as emo-
tional and spiritual care. We should have the right to protect ourselves from illnesses.

Ethical problems involving managed care

‘How should I provide safe and complete nursing care to clients who are dis-
charged too early from the hospital?’ A student explained:
I am scared that people will suffer greater injury. It is my responsibility to make sure
that the client learns what he/she needs to know. But where does my responsibility
end? I may forget something of serious importance because I do the job every day. Our
hands are tied when administration and insurance companies rule what care is given.
How can we expect people to have trust in our decisions and send them home with
equipment or treatments they are afraid of?

The basic nature of nursing students’ experience of ethical

problems
Conflict about the right thing to do
Like the AIDS patients and the elderly participants,14,15 the students described
conflict about what to value, who to be, and what to do. Some students thought
that there was a right way to resolve their conflict, but for various reasons they
did not or could not do it: ‘Ethical matters can arise even if I’m not making a
conscious choice to violate my values.’ Psychological, ethical and spiritual con-
flicts blended together, as one student stated: ‘I am involved in these people’s day
to day care, and it breaks my heart – all I can say is I wouldn’t want to be in that
bed.’
Conflict arose because the students desired both quality care and good
relationships: ‘The thought crossed my mind not to say anything. I felt conflict

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438 ME Cameron et al.
because I was afraid of being looked at as incompetent.’ Often, they viewed them-
selves as victims of nurses, physicians and the system: ‘Being a student, I felt the
doctors knew best, and I would go along with them, even though it was frus-
trating and didn’t feel right.’

Resolution of the conflict

The students, like the AIDS patients and the elderly participants,15 used a virtue
perspective to act with integrity. In general, they defined integrity as behaving
according to their best values: ‘I felt relieved after making that decision, because
I knew I had made the right one.’ This led to meaning, seeing life as part of a
bigger, purposeful picture:
I believe in doing what’s best for the client, even if it means having to face a conflict
with an RN. I don’t believe in doing something against what an RN tells me, but if I
find something wrong with what I’m supposed to do or with what’s taking place, I
believe in speaking up to someone.
To develop effective resolutions, they had to confront feelings about loyalty and
betrayal:
As a student nurse, I am supposed to go by what the nurses tell me, because they know
best. But this nurse was using very poor judgement and was not giving good care to
her client. I kind of had to go behind my nurse’s back, and I didn’t know if that was
right. My resolution turned out very well because my nurse did not end up feeling
betrayed by me, and yet my client got what she needed.
Many students took a passive approach: ‘Because I was an aide, there was not
much I could do.’ One student wrote: ‘Being new, I was unsure as to what my
role was.’ Another student stated: ‘I really didn’t feel I was in a position to raise
waves when I was only a part-time summer employee.’ Passivity exacted a toll,
however: ‘Each time I would see and hear this, it hurt me deeply. I should have
done something, but I didn’t. I withdrew and didn’t do anything, and I’m not
proud of that fact.’

Rationale for the resolution

The students’ rationale focused on doing what was ‘in the client’s best interest’.
Some students supported clients’ choices, without answering the larger questions:
I have struggled inside and out with how to deal with this, and so far the only reason
I can come up with is that it is not our job to decide who is going to live or die. We
can only do our best with who we have in front of us. Each and every life is a worthy
one, and I can’t take one to save others.
The AIDS patients and the elderly participants said that ethical listening was
therapeutic.15 Similarly, the students reported that examining their rationale was
helpful to them.
It taught me to own my mistakes and face the possible consequences. It taught me that
anyone can make a mistake, and to be sure to get all the facts before I make judge-
ments on another person’s behaviour.

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 Ethical problems and decision-making models 439

Nursing students’ experience of using an ethical decision-making

model
Tables 2 and 3 provide an overview of the students’ experience of using an eth-
ical decision-making model. Of the 73 students, 62 (85%) found the model to be
useful.

Model simply helped

The students wrote that the model helped them to understand their conflict,
develop a resolution and a rationale, and express their values and feelings: ‘What

Table 2 Frequency of ethical decision-making models used to resolve ethical

problems in five content categories

Content category Ethical decision-making model No. students

BC CJ FR TH VBD

Health professionals 6 7 8 7 4 32
Quality of life/death 2 4 1 8 4 19
Client’s behaviour 1 7 1 1 3 13
Contagious diseases 2 0 0 0 4 6
Managed care 0 1 1 0 1 3
Totals 11 19 11 16 16 73

BC, action guides of Beauchamp and Childress16; CJ, Caring and justice ethical
decision-making model13; FR, Frankena’s mixed deontological theory of
obligation30; TH, Thiroux’s universal ethical principles33; VBD, ‘value, be, do:
guidelines for resolving ethical conflict’29.

Table 3 Nursing students’ reactions to using ethical decision-making models

Reaction No. %

Model helped(n = 62; 85%)

Model simply helped 41 56
Model helped, but my resolution remained the same 16 22
Model helped, but didn’t resolve my conflict 3 4
Model helped, but it has some disadvantages 2 3

Model did not help 6 8

Student did not address reaction 5 7
Total 73 100

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440 ME Cameron et al.
it did was get me to look at the whole picture.’ They thought a model would
assist them in the future:
Using a model helped me to be more systematic and logical in my approach when
resolving my dilemma. I feel the models made me look at the situation in a more com-
prehensive manner. Now that I have been introduced to the five ethical decision-mak-
ing models, I have resources to deal more effectively with ethical problems in my future
practice.

Model helped, but had limitations

The students wrote that the model did not change the first essay’s resolution, but
it assisted in analysing the issues, provided ethics language, and would help in
the future. Five criticized the model for not identifying a resolution, focusing on
feelings, or giving too much to consider. Even so, the students found the model
to be helpful:
I haven’t really resolved anything, but only raised many more questions. However, I
think that by using the model to sort out my thoughts and to think about the dilemma
in very distinct categories, I have been able to resolve it in a way that seems accept-
able to me and puts my mind at ease.

Model did not help

Six students said the model did not help: their resolution stayed the same, the
model was vague, or the model was incongruent with their values. Their reac-
tions suggested that they did not understand the model, illustrating the impor-
tance of good teaching.

Discussion
Content and basic nature of nursing students’ experience regarding
ethical problems
The literature addresses many of these students’ ethical problems, but little atten-
tion has been given to conflict with colleagues. We will focus on this conflict. The
research by Han and Ahn1 supports our findings because Korean nursing stu-
dents experienced conflict when nursing staff deviated from principles, made a
medication error due to negligence, did not report a medication error, failed to
use an aseptic technique, withheld information about a colleague’s drug abuse,
and clashed over differing educational levels.
Studies of nurses have suggested that conflict with colleagues is widespread.
Dutch nurses felt conflict when colleagues treated clients aggressively, behaved
in incompetent and unauthorized ways, were indecisive, sedated clients for con-
venience, had insufficient knowledge, discriminated against clients, kept silent
about errors, and administered treatment against clients’ wishes.34 Israeli nurses
reported that four out of 10 most frequent and problematic ethical dilemmas were
an inability to treat patients owing to staff shortages, indecision about reporting
an incompetent nurse or physician, offensive behaviour toward a client, and
treatment perceived as mistaken or wrong.35 Swedish preoperative nurses viewed
most conflicts as caused by physicians and nursing staff.36 American nurses

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 Ethical problems and decision-making models 441
expressed concern about colleagues withholding information and breaking
rules37 and their inability to be client advocates.38 In these studies, conflict arose
because of time constraints, lack of staff, scarce resources, and a demand for
increased effectiveness. Nurses felt powerless to give quality care, because they
had a low status in hierarchical, bureaucratic organizations.39 The students
described their status as even lower than nurses, as one student noted:
Do I inform her superior, or will this incident be taken lightly, and in the end no one
will take my concern seriously? Will my voice have any effect? I see two conflicts. The
first has to do with the action and apathy of the nurse. The second has to do with my
not being willing to take a stand and risk being ignored.
Another student wrote:
In hospitals, there is a great demand on nurses’ time. Even when they are organized
and efficient, the nursing tasks are rushed to be completed. I am well aware of the pres-
sure to get everything done, having been a nurses’ assistant. The dilemma arises
between the nurses’ schedules and clients’ welfare.
The students longed to work well with colleagues. Being disloyal and break-
ing trust troubled them. They did not want interpersonal conflict to interfere with
good care.
This does not need to be a game between the nurses of who gets into trouble and who
does not. The well-being of many individuals is in the hands of nurses, and we must
work together to offer the best care possible.
Ninety-two per cent of the students were women, so there were not enough
data to determine if these results were gender related.
These findings illustrate the importance of reasonable job expectations. Nursing
students learn an ideal way to provide care, but they soon discover that nurses
‘in the real world’ may not practice this way. For example, nurses may attempt
to accommodate an increasing workload by taking questionable short cuts that
can threaten clients’ safety, nurses’ integrity, and the professionalism of nursing.
The line between short cuts and unethical practice is subtle and easy to cross. The
students viewed as unprofessional nurses who took unsafe short cuts. Nurses
were their role models, so they felt confused about whether to take short cuts too,
and compromise their integrity.
Furthermore, the results point to the necessity of developing ethical re-
lationships. Cameron and Moch40 suggest six characteristics of an ethical rela-
tionship: caring, appropriate boundaries, fairness or justice, integrity, respect and
trust. Nursing staff, as described by the students, did not realize they were caus-
ing conflict. In another study, nurses focused on legal issues regarding nursing
assistants, not ethical relationships with them.41 Manderino and Berkey42 found
that physicians’ verbal abuse of nurses took a heavy toll on nurses’ well-being.
Unethical relationships cause exploitation, dissatisfaction and inferior results,
whereas ethical relationships lead to personal development, satisfaction and qual-
ity care. By developing ethical relationships, nursing students, nurses and other
health professionals can reduce conflict with each other.40

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Nursing students’ experience of using an ethical

decision-making model
The students liked choosing a model that fitted their situation, as one student
said:
This model helps to sort out the pros and cons of each side of the choice. When it comes
to a tough decision, one usually has to choose the one with the greater amount of pros,
with less cons, not the choice with all pros and zero cons.
A total of 38 students (52%) chose the three principlism models, as listed in
Table 2. Some reasons may be that principlism was familiar, the students liked
principlism, or the model fitted their conflict and values. Nearly twice as many
students selected the caring and justice ethical decision-making model13 as
Frankena’s mixed deontological theory of obligation30 or the action guides of
Beauchamp and Childress,16 writing that the principlism models were too
abstract. A student explained: ‘With the caring and justice model, I can use my
heart and my head.’ Students who chose ‘value, be, do: guidelines for resolving
ethical conflict’29 preferred to develop their own values, rather than have pre-
scribed guidelines or principles, as in the other models.
The results suggest that nursing students who choose to use one of these mod-
els develop philosophical tools for resolving conflict. One student wrote: ‘This
experience showed me the importance of thinking out actions before they hap-
pen and problem solving before and during the time I give care.’ If nursing ethics
educators focus on one theory of ethics, such as principlism, students may not
find the help they need. Learning to use a model’s ethics language can promote
speaking up when something is wrong. Students must hear clearly that conflict
with colleagues and unethical behaviour is not inherently part of nursing. They
deserve a respectful, safe, supportive work environment. When they feel empow-
ered, they will be more likely to be able to stop abusive behaviour directed
towards themselves.42,43

Implications for nursing research, ethics education

and practice
We are collaborating with Dr Sung Suk Han1 and have conducted similar research
at two universities in Seoul, Korea. At Seoul National University College of
Nursing, 48 nursing students participated, and 49 at the Catholic University
College of Nursing. The results are being analysed. We plan to compare the
Korean and American nursing students’ experience of ethical problems and their
use of the five ethical decision-making models. The Korean research will provide
a cross-cultural perspective and test the ethical decision-making models in a non-
western culture.
Additional research is needed to determine if the choice of a model is related
to gender, content or values. A longitudinal study would examine whether the
nursing ethics seminar and the models benefit students after graduation.
The results of this study suggest six implications for nursing ethics education:
• Address students’ actual ethical problems: Start with ethical problems that

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 Ethical problems and decision-making models 443
students care about and trouble them. Then discuss ethical problems that
may confront them as graduates on personal, institutional, professional and
societal levels. Help them to develop the ability to engage in ethical
enquiry.38,44
• Offer students a selection of normative theories of ethics and ethical decision-
making models: Include virtue ethics, principlism and ethical caring, as well
as cross-cultural ethics and diverse wisdom traditions.45 Assist students to
evaluate the theories and models so they each develop a conceptual frame-
work for resolving ethical conflict that is consistent with their best values.
• Present interdisciplinary ethics research: Help students to apply ethics
research, such as this study’s results, so they develop effective resolutions to
conflict.
• Discuss professional standards: Assist students to resolve conflict by learning
professional codes of ethics, health professionals’ ethical and legal rights and
responsibilities, organizational and institutional standards, and research ethics.
• Promote ethical behaviour and relationships: Teach strategies for resolving
conflict with colleagues. Guide students to engage in critical analysis so they
act with integrity and meaning. Be a role model of someone who behaves
ethically.46,47
• Encourage ethical listening: Assist students to develop the skill of ethical lis-
tening13,15 to each other, nursing staff, clients and other health professionals.
By teaching students in an interdisciplinary setting, they may learn how to
speak with and listen to other professionals, and resolve ethical conflict before
it escalates.
Regarding nursing practice, the finding that 40% of the students’ ethical prob-
lems involved nursing staff suggests a serious issue. Nursing students mirror the
behaviour of practicing nurses. Although the students’ reactions may be dis-
missed as idealistic, they can be interpreted as a plea for nurses to recognize how
their actions impact on students. After graduation, nurses are likely to take on
the behaviours of their mentors when they encounter hierarchical structures. If
nurses do not conform to practice norms, their ethical conflict may increase and
they may leave the profession or practice setting. Nursing students need effective
role models so that they, in turn, will practice ethically.
In summary, the findings suggest that nursing students do not experience eth-
ical problems in the same way as graduate nurses. Their status is lower, so they
feel even more powerless to resolve conflict. Effective nursing ethics education
starts with nursing students’ actual experience, addresses conflict with colleagues,
offers a variety of theories of ethics and decision-making models, and promotes
ethical behaviour and relationships. The models presented here provide philo-
sophical tools that can help students to frame their distress as ethical conflict and
resolve it effectively. When nursing students lack good role models, however,
ethics education is not sufficient for ethical practice. Practice norms and hierar-
chical structures may compromise new graduates’ desire to practice ethically. The
nursing profession not only needs to provide ethics education for nursing stu-
dents but also nurses who are effective role models and practice ethically, even
in challenging work environments.

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Acknowledgements
The authors wish to thank Professor Shake Ketefian, Director of
Doctoral/Postdoctoral Studies and International Affairs, University of Michigan,
School of Nursing, Ann Arbor, MI, and Professor Young-Rhan Um, Department
of Nursing, Soonchunhyang University, Chonan, Korea, for editorial suggestions.
Bethel College, St Paul, MN, funded this research and ‘A model for teaching nurs-
ing ethics’. The National Institute of Nursing Research and the University of
Minnesota Graduate School funded ‘Ethical problems experienced by persons
with AIDS’. The National Institute of Nursing Research funded ‘Ethical problems
experienced by elders’.

Miriam E Cameron, University of Minnesota, Minneapolis, MN, USA.

Marjorie Schaffer, Bethel College, St Paul, MN, USA.
Hyeoun-Ae Park, Seoul National University, Seoul, South Korea.

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Appendix 1
Ethical decision-making models
Model integrating virtue ethics, principlism and ethical caring
Value, be, do: guidelines for resolving ethical conflict29:
• What should I value? Develop values that are ethically justifiable and give
meaning to life, such as not hurting, doing good, caring, justice, advocacy and
truth-telling.
• Who should I be? Develop excellent character by behaving with integrity
according to the values from the previous question.
• What should I do? Develop a resolution to ethical conflict that is consistent
with the answers to the previous two questions and takes into account both
right action and good consequences.
Note: Resolve ethical conflict by using the partial, personal, subjective perspec-
tive of ethical caring and the impartial, impersonal, objective stance of principlism
to answer the questions.

Models based on principlism

Action guides of Beauchamp and Childress16:
• Nonmaleficence: Do not harm.
• Beneficence: Prevent harm, remove harm and do good.
• Autonomy: Be self-governing and allow other people to be self-governing.
• Justice: Give to people their right or due.

Frankena’s mixed deontological theory of obligation30:

• Justice: Treat people as equals in the sense of distributing good and bad equally
among them.
• Beneficence: Do not harm, prevent harm, remove harm and do good.

Thiroux’s universal ethical principles33:

• Individual freedom: View everyone as having individual differences; give peo-
ple the freedom to choose their own ways and means of being moral.
• Goodness or rightness: Strive to be a good person, and perform right actions;
try not to be a bad person, and avoid performing wrong actions.
• Truth-telling or honesty: Engage in meaningful communication.
• Value of life: Revere life; accept death.
• Justice/fairness: Treat everyone fairly and justly in distributing good and bad
among them.
Note: Resolve ethical conflict by using an impartial, impersonal, objective stance
to apply the principles.

Model integrating ethical caring and principlism (justice)

Caring and justice ethical decision-making model29:
• Caring: Compassion – be empathetic; virtue – be a good person; values –
live up to what is desirable and ethically justifiable; and advocacy – be
supportive.

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 Ethical problems and decision-making models 447
• Justice: Universalizability – do what I can rationally will for everyone to do
in a similar situation; utility – do what will bring about the most good for the
most people; autonomy – govern myself and allow other people to govern
themselves; and fairness – treat all people equally according to their merits,
needs and abilities.
Note: Resolve ethical conflict by using the partial, personal, subjective stance of
ethical caring and the impartial, impersonal, objective stance of principlism to
apply the guidelines.

Appendix 2
Research method combining ethical enquiry and phenomenology
• Investigate a phenomenon by collecting data about senior baccalaureate
nursing students’ experience of ethical problems involving nursing practice
and use of ethical decision-making models.
– First essay – students engage in descriptive ethics when they examine their
experience of an ethical problem involving nursing practice.
– Nursing ethics seminar – students learn how to do normative ethics and
meta-ethics by using five ethical decision-making models.
– Second essay – students engage in normative ethics and meta-ethics when
they use one of the models to resolve their ethical conflict from the first
essay and they evaluate the model.
• Investigate essences by analysing each essay to answer the research questions.
– Transcribe each essay to computerize the data.
– Each student discussed conflict, resolution, and rationale, so use word
processing to organize all the data from the first essay according to those
topics.
– State the essence of the student’s self-reported ethical problem in the
student’s own words.
– Use word processing to organize all the data from the second essay accord-
ing to the principles, guidelines, or questions of the student-chosen model,
and the student’s evaluation of the model.
– Highlight ethical terms, such as ‘good person’, which the student used and
defined.
• Identify relationships among essences by analysing across essays to answer
the research questions.
– Describe and examine essences of the content categories that emerge.
– Describe and examine essences of the basic nature of the students’ ethical
problems.
– Describe and examine essences of the students’ use of ethical decision-
making models.
– Address implications for nursing research, ethics education and practice.

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