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FACTORS INFLUENCING ETHICAL DECISION MAKING AMONGPSYCIDATRIC NURSES AT MATHARI HOSPITAL IN NAIROBI.

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF THEREQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTER OF

SCIENCE IN NURSING (MENTAL HEALTH AND PSYCHIATRIC NURSING) OFTHE SCHOOL OF NURSING SCIENCES, UNIVERSITY OF NAIROBI

BY

IRENE GACHERI MAGETO

REG. NO. H561P170449/07

Septem ber 2009

-

DECLARATION

I, Mageto Gacheri Irene declare that this dissertation is my original work and has not been

presented for an award of a degree in any other university.

Signature ..~I:~ Date.J.(fi?r.fqJ. .

ii

CERTIFICATE OF APPROVAL

This dissertation has been submitted with our approval as the University Supervisors.

1. The late Prof. Joyce 0 Musandu,

PhO, MScN, DAN, KRN, KRM, KRCHN.Oirector and Senior Lecturer,

School of Nursing sciences, University of Nairobi

2. Dr Margaret N Chege,

PhO, MPHE, BScN, DAN, RN/RM/PHN

Lecturer, Sch 01 of Nursing Sciences, University TNairObi

Signature... .d(;...........Date.HfL~J

3. Dr James Mwaura,

PhD, MSc, BScN

Lecturer, School of nursing Sciences, University of Nairobi

Signature ~ ..~: Date /6.:~.tep..~1

iii

DEDICATION

To my husband Peter, son Teddy and daughter Chrystal for their patience, support and

encouragement during the writing ofthis proposal. You are the wind beneath my wings!

To my late brother Mwirigi. May you rest in eternal peace Mbiiri.

To all psychiatric nurses who dare to care for the mentally ill.

iv

ACKNOWLEDGEMENT

I wish to acknowledge the help of my supervisors the late Prof. Joyce Musandu, Dr. Margaret

Chege and Dr. James Mwaura in working and walking with me through this dissertation.

Without your help this project would not have been a success. Please keep up the helping

spirit.

I also wish to appreciate the efforts ofMrs Mirriam Wagoro for guiding me through the right

path of thinking in research terms and constructive critique of the first draft of this work.

Many thanks go to Mr. Lawrence Muthami for teaching me biostatistics, Dr Michael Bowen

for helping me with statistical analysis of data and to Mr. Martin Mutisya for being available

for biostatistical consultations.

I thank my colleague Nancy Michire for her constant appraisal, critique and encouragement.

You always kept me on my toes! Thanks also to the administration of Mathari Hospital for

allowing me to access my study population and to all those nurses who participated in the

study. Many thanks to my research assistants for their dedication and support through out the

data collection period.

I appreciate the School of Nursing Sciences of the University of Nairobi for the good learning

atmosphere.

To you all, GOD BLESS YOU abundantly!

v

TABLE OF CONTENTS

DECLARATION .ii

CERTIFICATE OF APPROVAL iii

DEDICATION iv

ACKNOWLEDGEMENT v

TABLE OF CONTENTS vi

LIST OF FIGURES ix

LIST OF TABLES x

LIST OF ACRONYMS AND ABBREVIATIONS xi

DEFINITION OF OPERATIONAL TERMS xii

ABSTRACT xiii

CHAPTER ONE: INTRODUCTION 1

1.1 Background 1

1.2 Research problem 2

1.3 Justification of study , 3

1.4 Research questions 3

1.5 Study objectives 4

1.5.1 Main Objective 4

1.5.2 Specifc Objectives: 4

1. 6 Hypothesis 4

CHAPTER TWO: LITERATURE REVIEW 5

2.1 Introduction 5

2.2 Ethical decision making 5

2.3 Theoretical framework 9

2.4 Ethical principles 10

2.5 Professional codes and international agreements 11

CHAPTER THREE: MATERIALS & METHODS 13

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3.1 Research design 13

3.2 Variables under study 13

3.2.1 Independent variables 13

3.2.2 Depedent variable 13

3.2.3 Confounding variables 13

3.3 Study area 14

3.4 Study population 14

3.5 Inclusion and exclusion criteria 14

3.5.1 Inclusion criteria 14

3.5.2 Exclusion Criteria 14

3.6 Sample size determination 15

3.7 Sampling procedures 16

3.8 Study instrument. 18

3.9 Training of research assistants 18

3.10 Validity and reliability 18

3.11 Data collection 18

3.12 Data management 19

3.12.1 Data cleaning and entry 19

3.12.2 Data analysis and presentation 19

3.13 Ethical considerations 19

3.14 Study assumption 20

3.16 Conceptual framework 20

CHAPTER FOUR: RESEARCH RESULTS 21

CHAPTER FIVE:DISCUSSION, CONCLUSION AND RECOMMENDATIONS 33

5.1 Discussion 33

5.2 Conclusion 39

5.3 Recommendations 39

vii

TIME PLAN 40

BUDGET 41

REFERENCES 42

APPENDICES 46

APPENDIX I: Questionnaire for nurses 46

APPENDIX II: Focus group discussion 51

APPENDIX III: Consent explanation form 52

APPENDIX IV: Letter of approval from knh ethics and research committee 53

APPENDIX V: Letter of Approval. 55

APPENDIX VI: Letter of authorization 56

APPENDIX VIII: Map of showing location ofMathari Hospital... 57

viii

LIST OF FIGURES

Figure 1: Interaction between variables affecting ethical decision making 20

Figure 2: Respodents age 21

Figure 3: Respodents gender 22

Figure 4: Respodents' marital status 22

Figure 5: Respodents qualifications 23

Figure 6: Respodents designation 24

Figure 7: Staffing ratios 26

Figure 8: Results of disclosure of patients diagnosis 28

ix

LIST OF TABLES

Table 1:Sampling frame 17

Table 2: Respondents years of practice 25

Table 3: Respodents' Psychiatric experience 26

Table 4: Nurses reaction to patients refusal of medication 29

x

BScN

DOH

ECHR

ECN

EN

ERB

FMA

ICN

KNH

KRM

KRN

MScN

PMHNE

SPSS

UK

UNWMA

LIST OF ACRONYMS AND ABBREVIATIONS

Bachelor of Science in Nursing

Declaration of Helsinki

European Commision on Human Rights

Enrolled Community Nurse

Enrolled Nurse

Ethical Review Board

Finnish Medical Association

International Council of Nurses

Kenyatta National Hospital

Kenya Registred Midwife

Kenya Registred Nurse

Master of Science in Nursing

Psychiatric Mental Health Nursing Education

Statistical program for social sciences

United Kingdom

United Nations

World Medical Association

xi

DEFINITION OF OPERATIONAL TERMS

Ethical decision: A moral decision made in regard to patient care.

Ethical decision making: Trying to distinguish right from wrong in situations without clear

guidelines.

Ethical dilemma-A situation that arises when the nurse is expected to choose between two

equally unsatisfactory alternatives.

Ethical theory: A theory that deals with the standards and principles of moral reasoning and

enables the nurse to reach a conclusion about what should be done.

Nursing ethics: The formal study of ethical issues that arise in the practice of nursing .In

this study, it will be viewed as a guide to the analysis used by nurses to make ethical

judgement.

Psychiatric nurses: All licenced nurses working at Mathari Hospital.

Psychiatric nursing:The specialty within nursing that deals specifically with human

responses to mental problems.

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ABSTRACT

Ethical decision making is the process of trying to distinguish right from wrong in situations

without clear guidelines. While ethical dilemmas confront nurses in all areas of nursing

practice, those that occur in psychiatric nursing are more challenging than those occurring in

other areas of nursing. This is because the decrease in mental ability of psychiatric patients

leads to vulnerability which evokes ethical difficulties for the psychiatric nurses.

This was a descriptive cross-sectional study aimed at identifying the factors that influence

ethical decision making among psychiatric nurses in Kenya. It was carried out at Mathari

hospital in Nairobi.

The study aimed at identifying factors that influence the process of ethical decision making

by the psychiatric nurses in their clinical practice. The study hypothesis was that there is no

relationship between nurses' demographic characteristics and the way they make ethical

decisions.

Quantitative data was collected using a self administered questionaire which was developed

and distributed to 152 randomly sampled psychiatric nurses at Mathari hospital. Qualitative

data was collected via a focused group discussion which comprised of eight randomly

selected charge nurses. Data was categorized and coded depending on the variables. Data

entry was done by use of SPSS (version 16.0) statistical package. Desciptive and inferential

statistics were used as appropriate for data analysis. For example, Spearman's Rank order

was used to express correlation between variables. Qualitative data from focused group

discussions was ana lysed manually.

Overall the results of this study showed that factors influencing nurses ethical decision

making were professional experience(r=0.040,p=0.01), workload (rho=0.227,p=0.042),

psychiatric nursing experience(r= 0.037,p= 0.01) and gender(rho=0.277,p= 0.013). There is

need to consider knowledge and skills obtained through psychiatric care specializations when

posting nursing staff to the psychiatric care areas. More research (using both quantitative and

qualitative approaches) need to be done to identify what other aspects of the clinical

environment affect ethical decision performance by nurses.

xiii