Ethical Dilemmas Experienced by Nurses in the Critical Care Units in Kenyatta National Hospital
Introduction- Ethical issues have emerged in the recent years as a major component of health care for the critically ill patients, who are vulnerable and totally depend on the caregiver, optimally the nurse working in the critical care unit. As a result nurses working in the Critical Care Units are faced with ethical dilemmas on a day to day basis in the course of executing their duties. Ethical dilemmas have therefore become one of the priority concerns in the nursing profession that require urgent attention in Kenya. As the provision of care to the critically ill becomes more complex due to technological advancement, and the profession of nursing more autonomous, professional accountability cannot be overemphasized. (Fry, 2002). The complex nature of the health problems faced by patients admitted in ICU coupled with extensive use of very sophisticated technology requires at times rapid decision making. Ethical dilemmas confront even the most experienced nurse (Breen C.M. et al, 2004). Those working in KNH ICU are not any different particularly considering particularly considering that KNH is public hospital having the biggest ICU in the country. Additionally it admits patients from various walks of life and the nurses have diverse socio- demographic factors. However their perception and magnitude of ethical dilemmas they face while working in these areas and how they resolve them have not been studied. Duration of the study: The study took five weeks. Pretesting of the questionnaires took two days. Objective: To explore ethical dilemmas experienced by nurses working in the critical care areas at Kenyatta National Hospital and factors influencing the nurses‟ ethical decision making. Study question: What ethical dilemmas face nurses working in the critical care areas at KNH and how do they resolve them? Materials and methods: An exploratory survey study design was adopted whereby 123 nurses shall be requested to participate in the study upon signing an informed consent. These participants were employees of KNH working in the critical care areas during the time of data collection. The study was conducted in the critical care units of KNH. Permission to conduct the study was sought from the KNH management. Clearance to conduct the study was sought from University of Nairobi and KNH ethical research committee. Sampling was done using simple random sampling method whereby 123 nurses were picked from the total of 184 nurses. Out of these 3 did not return the questionnaires. Questionnaires were distributed to the participants to give the information needed. Data management: Upon completion, data was cleaned and analyzed using SPSS. Chi square test was used to assess the relationship between variables. Finally, propositions and conclusions were made based on apparent patterns or relationships within the data. Results: This study on has sought to ascertain what nurses experience as ethical dilemmas while working in the critical care areas and how they have dealt with these issues. The dilemmas which were of major concern to nurses included: prolonging the dying process, withdrawing/ withholding treatment, resuscitation (DNR) orders (table 8), unsafe nurse- patient ratios and allocation of scarce medical resource, rights of pediatric patients, and nursing of critically ill patients who may pose a risk to the nurses. In dealing with the issues majority of the nurses of the respondents indicated that they would consult with the physicians. Others reported to the nurse team leaders while a few made decisions without consulting a third party. Some socio- demographic factors were shown to influence the experience of ethical dilemmas by the respondents. These included: the age, level of knowledge on ethical issues, professional qualification and availability of work place resources. It was noted those aged below 35 years experienced more dilemmas than others while those whose level of knowledge was low experienced less dilemmas probably due to their inability to identify the dilemmas as accurately as those more knowledgeable. Those who reported to have adequate work place resources experienced fewer dilemmas. They probably knew the channels to follow to resolve issues compared to their colleagues who reported inadequate resources. Conclusion and recommendations- this study shows that ethical dilemmas are an issue of concern among the nurses working in the critical care units of the KNH. The experience of ethical dilemmas is influenced by various socio- demographic factors. In resolving the dilemmas most nurses would consult the Doctors showing that probably the profession is still at the place of subordination to the medical profession. It is notable that some nurses chose to make decisions without consulting. They may probably be confident of their ability to solve problems without involving a third party. Results of the study will be used to make recommendations for shaping of the curriculum for training of critical care nurses to include ethical decision making process as this need for education on ethical issues has been identified as shown in the results. The findings can be utilized as literature for further research on ethical issues.