Magnitudes y unidades

Underpinned by a marked political ideological shift from egalitarianism to neoliberalism, the first part of this review has outlined the context and processes of rapid and broad economic and political reform in New Zealand from 1980 to 1999. Transcending public policy and structure, neoliberalism has in its wake transformed social policies and structures to fundamentally alter the organizations, objectives, processes and values of New Zealand’s health care system.

Manifestations of neoliberalism in the institutional context, public management theories applied in New Zealand’s public institutions, such

as agency, public choice and new public management, along with their political and economic objectives and activities, spawned repeated restructuring of the health sector in New Zealand between 1984 and 2001. New public management theory or managerialism in the health sector, both in New Zealand and other countries, has had and continues to have a marked impact on health care organizations. Derived from the entrepreneurial context of the private sector, managerialism focuses on outputs, effectiveness, efficiency, social responsibility and fiscal prudence in the utilization of public health resources. Managerialism in the health sector has not however been without significant criticism.

As the largest and most visible profession in health care, nursing has been greatly affected by reform and managerialism. Professional nursing in New Zealand as elsewhere in the globe has been restructured several times in the last two decades with a number of consequences. Nursing leadership structures at all levels of health care organizations have been weakened, and at times completely abolished, resulting in a threatened and vulnerable profession. The quality of nursing care has been eroded and patients have suffered the affects to their health by way of poor health care outcomes. Nurses have been personally affected by reform, including ill health, injury and burnout, to such an extent that there is now a global nursing shortage. Nurses who remain in health care service, and those yet to come, practice in a context fraught with tension between the values of their profession and the values of the health care organization charged with fiscal accountability and stewardship for health resource utilization. It is a context that renders nurses and in particular nurse managers, vulnerable to ethical conflicts as they strive to provide the care they and their profession believes is right and necessary for their patients.

Ethical conflict arises from values differences or clashes between the health professional and health care organization, and may have a

number of implications for both patients and nurses. Whilst patients may experience increased discomfort or suffering as a consequence of poor care, impacts on the health professional include resignation, burn out and loss from the profession primarily as a consequence of suffering moral distress. A review of the literature on ethical conflict in the nursing revealed both empirical and theoretical insights that primarily focused on the experience of ethical conflict and moral distress for clinical practising nurses. One study was located which explored ethical conflicts which clinical practising nurses have with their employing organizations, and only one study to address the concept and experience of nurse managers’ ethical conflicts with their health care organizations.

The study by Gaudine and Beaton (2002) revealed that nurse managers’ experience ethical conflict as one that renders them voiceless in their attempts to determine how best to meet the competing needs of individual patients and the health care organization. It was also an experience that may result in unjust practices on the part of the health care organization such as unfair workloads and terminations (Gaudine & Beaton, 2002). Factors that mitigated this experience for the nurse manager include support from other nurse managers, hospital ethics committees and the nurse managers’ families. Factors which made the experience of ethical conflict for nurse managers worse include fallout from unsafe nursing care, and an inability to resolve situations. The outcomes of ethical conflict revealed by this study included negative feelings, turnover and being silenced. Key values at issue and identified in this research concerned the quality of patient care and fair treatment of nursing staff.

Rationale for the present study

Contemporary emphasis in the management of health services toward efficiency and effectiveness in public health resource utilization situates

nurse managers in an inevitable context of values tension. This context creates risk of the experience and negative consequences of ethical conflict for nurse managers, patients, nursing staff and health care organizations. This chapter has revealed that whilst the concept and problem of ethical conflict is understood, it has not been well researched from the perspective of nurse managers; with only one qualitative study found in the literature search that particularly addresses the phenomena from this view point (Gaudine & Beaton, 2002).

When little is known of a particular phenomena and experience, qualitative descriptive studies assist in defining and conceptualizing that experience, as well as describing dimensions and variations of that experience (Polit & Tatano Beck, 2006). Replication studies in the quantitative research paradigm are of central importance for the verification or refutation of results or findings of some prior study (Ellis, 1994; Page & Meyer, 2000; Polit & Tatano Beck, 2006; Bryman & Bell, 2003). Replication also underscores the desire to check on cultural or ideological bias on the part of the researcher (Ellis, 1994) as well as providing the substance for systematic and meta-analysis (Eden, 2002). Whilst the usefulness of replication studies in qualitative research is almost ignored by the literature, perhaps on the basis of subjectivity in findings and severe limitations of generalizability of findings, this study is concerned with knowing and understanding more about real experiences others have encountered, and others have researched, but clearly to a very limited degree. Indeed Gaudine and Beaton advise that “...future research could examine ethical conflict as experienced by nurse managers working in other settings” (2002, p.32). At the very least, there will be broad points of contrast and comparison between the findings of the two studies from which refinement of concepts may proceed. It may also, from the perspective of triangulation in research, be usefully considered a second source of informants from which

conclusions may be drawn regarding the knowledge and findings generated (Bryman & Bell, 2003; Polit & Tatano Beck, 2006).

The research presented in this report is thus aimed at building on and enhancing knowledge of the experience of nurse manager’s ethical conflict with their health care organizations, in a New Zealand context. As previously noted by Gaudine and Beaton (2002) knowledge and understanding of the phenomenon is essential to resolution of ethical conflicts and mitigating its negative consequences. In contrast to the foundation study, this research did not seek to describe the experience of ethical conflict that nurse managers’ had with their professional associations, since the participants in this earlier study, mostly experienced no ethical conflict with their professional associations (Gaudine & Beaton, 2002).

CHAPTER 3 – METHOD

The purpose of this research is to build and enhance knowledge and understanding of the experience of nurse managers’ ethical conflict with their health care organizations. In order to achieve this purpose, this study seeks rich descriptions, themes and patterns of the experience, and to do so by replicating the qualitative descriptive approach of the study by Gaudine and Beaton (2002). Consistent with these research purposes, this chapter presents the methodological underpinnings, participant recruitment and selection, data collection and analysis for the study. It also sets out important ethical procedures and considerations, as well as an outline of the establishment of research rigour for the study. Some brief criticisms are made of the methods used in the foundation study, and as a consequence the adapted methods for analyzing qualitative descriptive data for the current study are set out.