"I don't know how ethical I am": an investigation into the practices nurses use to maintain their moral integrity
Pike, Adele Waring
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Registered Nurses work in hierarchical and gendered organizations. They face many of the same constraints and limits to their autonomy and decision making that subordinate workers in other occupations experience. The subordinate position of nurses in health care organizations interferes with their ability to act in accordance with their most cherished values and therefore challenges their ability to maintain their moral integrity. A qualitative study was undertaken to identify the practices nurses use to maintain their moral integrity and to discover patterns in nurses' use of these practices. Using Grounded Theory methods, seventeen randomly selected Registered Nurses were interviewed about times in their practices when their most cherished values were challenged or threatened by the decisions of more powerful others. Interviews were tape recorded, transcribed and analyzed using open coding technique. Analysis of the interview data revealed that nurses use four categories of practices to maintain their moral integrity: integrity-seeking practices, integrity-diminishing practices, integrity-repairing practices, and integrity-preserving practices. Data also indicated that nurses alternate or zigzag between all four practice categories in their attempts to act in accordance with their cherished values, rather than relying exclusively on practices in one category or steadily progressing toward an increased reliance on practices that preserve integrity. The findings of this study challenge the conventional concept of moral integrity as the unconditional commitment to fundamental values. They lend support, instead, to a sociological construction that considers moral integrity as the balancing of competing values. Moral integrity is constructed as a matter of degree rather than an all-or-nothing virtue. The findings argue for understanding the maintenance of moral integrity as a lifelong or career-long process of learning "to get it right" rather than the achievement of moral excellence. This research has implications for nursing practice. Chief among them is the need for nurses to better understand their sociological position in the organization of health care. Such an understanding will help nurses appreciate the challenges and complexity of maintaining moral integrity within the context of health care institutions. Additionally, this study points to the need for nurses and the Profession of Nursing to examine the integrity-diminishing practices nurses use. Many of these are subtle and insidious tactics, and nurses need to find more morally comfortable alternatives. Further research that involves theoretical sampling with a larger cohort of nurses will refine and further the hypotheses generated here. Such research may also help to identify the correlates of nurses' choice of integrity practice.
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