FROM CONCEPT DEVELOPMENT TO QUALITATIVELY DERIVED THEORY: ETHICAL SENSITIVITY IN PROFESSIONAL PRACTICE
The signs – sometimes imperceptible, at others very clear – are all around us. But they require careful interpretation if they are to be transformed into a road map.
The literature lacks clear guidelines for synthesizing results of concept analysis beyond conceptual categories toward the development of theory to guide practice. Except for the most simplistic models, concept development rarely leads to theory development. Pragmatic utility (Morse, 2000b), a balanced and systematic method to develop concepts, enables the examination of the interactions between attributes, modeling, and theory development. Depending on the state of science within a particular discipline or a combination of disciplines, the results of exploring pragmatic utility bring new knowledge into the conceptual bases to guide research, theory, and practice. In this chapter, I explore the processes used for taking analyses to a beginning level of qualitatively derived theory. I describe using pragmatic utility for examining the concept of ethical sensitivity in nursing and other professional practices to develop qualitative theory, and the methodological tools and processes involved in abstraction beyond the limits of concept analysis toward theory.
An extensive critical appraisal of relevant available literature on ethical sensitivity in professional practice was undertaken to inform ethical practice in the care and treatment of those with complex, poorly understood conditions (such as eating disorders). The inquiry was needed because clients and their families perceived their experiences with health services as traumatic, rather than as healing, despite professional expertise and good intentions (Weaver, 2012; Weaver, Wuest, & Ciliska, 2005). Furthermore, this perceived jeopardy was associated with care across multiple disciplines and posed as much a threat to client well-being as the health challenge itself. I wanted to learn how to deal with this perception and the situations that give rise to it. To begin to find answers for how nurses and other professionals might better address the moral complexities encountered in providing care and services, I needed a clearer understanding of the quality of ethical practice that enables professionals to accurately recognize and sensitively respond to the needs of those they serve. These aspects could potentially impact professions by influencing a professional’s behavior in a given situation.
As a scientific concept, ethical sensitivity has been explicitly defined within professional disciplines including nursing, medicine, dentistry, philosophy, business, education, psychology, bioethics, law, theology, journalism, and social and political sciences. Despite the volume of this work and the common definitions used, the available literature provided a clutter of competing descriptors for the concept of ethical sensitivity and only limited understanding of its nature, associated negative consequences, and the role of education in preparing professionals to develop their ethical sensitivity. Validity has been compromised through practices of not matching samples to the population (e.g., convenience rather than randomly selected samples), including only students as study participants, cueing participants to the presence of an ethical problem versus allowing them to recognize it on their own, failing to ensure accurate conclusions about relationships studied, and using inadequate underlying theoretical frameworks and definitions. Validity of this qualitative research was to some extent preserved because participants were asked to describe their own experiences of making decisions when working with vulnerable clients. However, without agreement about the core features and definition of ethical sensitivity, findings from individual studies could not be consolidated and further research would not significantly contribute to knowledge development.
CONCEPT ANALYSIS USING PRAGMATIC UTILITY
In seeking greater knowledge of the concept, I applied the guiding principles within the Morse criterion-based method for exploring pragmatic utility to clarify study purpose, selecting adequate and appropriate literature, comprehending the topic, and synthesizing results. The purpose of the inquiry was to:
• Understand the perspectives of professionals in providing care and services to clients, and
• Construct a basic foundation for ongoing and future investigation through exploring the usefulness and implications of the concept ethical sensitivity
This analysis used as data the published literature from a number of professional disciplines, and 200 published reports meeting the study’s inclusion criteria were included. Validity in selection of literature was attained through restricting search fields to articles with such related terms as ethical sensitivity, moral sensitivity, ethical perception, moral perception, ethical sensibility, moral sensibility, and ethical intuition in titles or abstracts. Inclusion criteria were accessibility, relevancy (i.e., publication contains an explicit or inferred definition of the concept), and usefulness to the emerging conceptualization. Additional data were included through ongoing searches and primary sources.
To comprehend the topic, publications were sorted and color-coded by discipline. Each publication was first read without coding to begin to holistically understand the concept and identify its dimensions without losing the connections between these dimensions and their context. Data were then coded, sorted into predetermined analytic categories of concept anatomy (internal structure) and physiology (action), and examined for fit within and across categories. Fit is used for identifying and matching characteristics of one entity with those of another entity to determine if similar characteristics are present (Morse & Singleton, 2001). In analyzing the anatomy and physiology of ethical sensitivity, fit determined if an entity was considered a component of these dimensions, and fit allowed data to be linked together to enable analysis, organization, conceptualization, and summarization while raising the level of abstraction.
As extensive knowledge was built about the concept, questions were formulated and asked of the literature to develop new insight and information. Results from such questioning were synthesized to produce a more comprehensive definition and interpretation of the concept of ethical sensitivity in professional practice that would better represent the phenomenon (Weaver, Morse, & Mitcham, 2008). Exploring pragmatic utility pulled knowledge beyond concept analysis to inform a mid-range theory beyond the expectations of the initial project.
EXPLICATING CONCEPT ANATOMY
Assessing anatomy involves examining the internal dimensions of the concept: its theoretical definition(s), preconditions, attributes, boundaries, and outcomes (Morse, 1995b). These dimensions form the categories for sorting data to enable the concept’s anatomy to be explicated and illustrated (Table 21.1).
Examination of concept anatomy revealed incomplete and diverse theoretical definitions for ethical sensitivity. It had been scientifically defined by researchers for use in specific studies with limited agreement of definitions across different studies. The conditions under which ethical sensitivity occurs were not fully explicated. Attributes of moral perception, affectivity, and dividing loyalties were identified but relationships between these attributes and their components were not clear. Ethical sensitivity was used interchangeably with its allied concepts (e.g., moral sensitivity, ethical intuition) indicating a need to clarify the concept’s boundaries. Positive outcomes of client comfort and well-being, professional learning, and integrity-preserving compromise were found in the professional literature; yet, negative consequences, which could reasonably include emotional overload, exploitation, and personal and moral distress, were meagerly considered with regard to ethical sensitivity.
Anatomy of the Concept of Ethical Sensitivity
ILLUSTRATIONS OF ETHICAL SENSITIVITY
Degree to which concept is communicated, which enables different people or the same person at different times to agree that something is an instance of the concept (Berthold, 1964).
Competing/incomplete definitions that involve one or more components of care, knowledge, affect, skill, and responsibility.
Circumstances that must be present for the concept to develop or the behaviors that distinguish the characteristics to occur.
Suffering and vulnerability cues, relationship, receptivity, responsiveness, and uncertainty precede incidents of ethical sensitivity.
Features always present in instances of the concept. Must be abstract enough to define the concept regardless of the context yet unique enough to differentiate concept from allied (similar) concepts.
Attributes: moral perception, affectivity, and dividing loyalties are identified in all instances of concept.
Separateness of the concept from others. Boundaries may be fuzzy or merge or overlap with other concepts (and thus share attributes).
Used interchangeably with allied concepts (e.g., moral sensitivity, ethical intuition, ethical perception, ethical sensibility).
Results or consequences from utilization of the concept.
Outcomes are client comfort and wellbeing, professional learning, and integrity-preserving compromise.
Adapted from Weaver and Morse (2006).
MOVING FROM ANATOMY OF THE CONCEPT TO ITS PHYSIOLOGY
Physiology or action of the concept was explored as described by Morse (1995a, 2000b) via examining its conceptualizations, perspectives, measurement, and applications in research and practice settings. In contrast to decontextualizing the concept’s anatomical dimensions, analyzing physiology recontextualized the data to understand the concept’s action in its various applications. Table 21.2 portrays the physiology of the concept across disciplines of nursing, medicine, business/accounting, theology, and dentistry.
Differences are revealed in how ethical sensitivity was conceptualized within and across these disciplines (e.g., as cognition and responsibility in dentistry compared to affect, cognition, skill, responsibility, and knowledge in nursing and theology). Different settings and perspectives (e.g., client and lay views in theology and business/accounting) were provided. Of the various measurement instruments used, the Lutzen Moral Sensitivity Questionnaire (MSQ; Lutzen, Johansson, & Nordstrom, 2000) was developed from qualitative nursing research and the Dental Ethical Sensitivity Test (DEST; Bebeau, Rest, & Yamoor, 1985) from hypothesized practice scenarios. Ethical sensitivity was most often evaluated quantitatively through scored responses to real life or hypothetical dilemmas (e.g., a choice between two or more equally good or bad options) or violations (e.g., infringement on rights and harm to stakeholders). The scenarios portrayed ethical sensitivity as a negative concept, that is, ethical sensitivity would not be applied to a situation if people were behaving ethically. Missing was conceptualization of ethical sensitivity as a positive, proactive component of practice.
EVALUATING CONCEPT MATURITY
Maturity or readiness of a concept for research is evaluated by establishing the degree of the concept’s coherence with the following principles: epistemological (clear description of definition, preconditions, attributes, boundaries, and outcomes), pragmatic (how well the concept is operationalized; its usefulness to and fit with other phenomena of interest to the discipline), linguistic (the consistency of the concept’s use in and across contexts), and logical (how well the concept holds its boundaries through integration with other concepts).
The evaluation of the maturity of ethical sensitivity was detailed in Chapter 11. Briefly, using the literature, evaluate the epistemological, pragmatic, linguistic, and logical dimensions of the concept. If the concept is immature, epistemologically there are no (or inadequate) definitions; the pragmatic criterion is not operationalized and fits poorly; the linguistic aspects are confused, and logically, it does not hold its boundaries.
If the concept is partially mature, epistemologically there will be multiple competing definitions; it will be partially operationalized; linguistically, partially linked with context, and linkages with other concepts will be partially developed.
Mature concepts are well defined epistemologically; they pragmatically fit with other phenomena and are operationalized; linguistically, they are integrated into other texts, and logically used in theory (Morse, Mitcham, Hupcey, Tasón, 1996; Weaver & Morse, 2006).
Establishing its maturity illuminates the current state of the science concerning a concept of interest (Penrod & Hupcey, 2005b). From this baseline assessment of maturity, ethical sensitivity was shown to typify a partially mature, emerging scientific concept that lacked consensus about its meaning, structure, and use. Introduced as a concept by Rest in 1982, ethical sensitivity is interchanged with its allied concepts (e.g., moral sensitivity). Although it was beginning to be used in research (e.g., measuring ethical sensitivity levels in various professional groups; Bebeau & Brabeck, 1989; Lutzen, Johansson, & Nordstrom, 2000), it has not been logically linked with other concepts. Epistemologically, ethical sensitivity presented as many definitions and needing greater explication and integration of its preconditions, attributes, and outcomes. Pragmatically, ethical sensitivity was conveyed as an aspect of a professional’s decision making; however, the focus of the decision making varied within and across disciplines. To illustrate, business, law, and nursing reported concern with client satisfaction; nursing and education with attrition; theology and philosophy with client comfort. The multiple descriptors for ethical sensitivity evident across disciplines could indicate linguistic immaturity; however, that is not the case if all these descriptors are components of ethical sensitivity. For this concept to be useful for theory, research, and practice, its plethora of definitions, descriptors, and differing perspectives required further development.
ADVANCING THE CONCEPT OF ETHICAL SENSITIVITY USING CRITICAL APPRAISAL
Described by Morse (2000b) as a process of formulating and asking a series of increasingly complex questions of the literature, critical appraisal enables analysis and synthesis of assumptions underlying the concept’s application in research and theory. Arising from and driven by in-depth understanding of the literature (as achieved through assessing the concept’s anatomy, physiology, and maturity), critical appraisal stimulates “thinking outside the box.” It provokes intense examination and direction beyond the limits of isolated findings and individual disciplines, and contributes to advancing the development of a partially mature concept by synthesizing new or hitherto unexplored tacit knowledge.
Carefully constructed questions are used to stimulate inquiry into aspects of the concept that are incomplete, confusing, or uncritically accepted. The questions must be clearly understood by all readers and singularly focused toward a significant line of inquiry within a substantive area and discipline. The questions have breath (able to address a wide range of application) and depth (ability to penetrate beyond obvious surface knowledge) to promote insight and illuminate the concept’s complexity. Prepared as a set, the analytic questions fully and completely address the concept in ways that permit a fair and comprehensive comparison of concept characteristics across disciplines by treating all perspectives respectfully and as equally important (Weaver & Morse, 2006). The analytic questions designed to examine the nature of ethical sensitivity, its requirements, and preparation for ethically sensitive practice are included in Box 21.1.
In comparing the answers to the analytic questions, the sample of literature was at times expanded to clarify emerging ideas. For instance, in examining the component of reflexivity as a quality for ethically sensitive practice (Analytic question # 7, Box 21.1), literature concerning whistle-blowing and moral distress was included in light of reports that professionals did not always act with ethical sensitivity despite having comprehensive knowledge of the situation (e.g., Austin, Bergum, & Goldberg, 2003; Cherrington, 2002; Ulrich, Soeken, & Miller, 2003). New information and insights emerging while examining the responses to the analytic questions were integrated using the principle of fit (explained in the section “Concept Analysis Using Pragmatic Utility”) and negative case analysis. Negative cases are examples of conflicting data that do not initially fit the pattern being discovered in the data (Glaser & Strauss, 1967). Negative cases rekindle researcher thinking about the data, often in new ways that round out and contribute to denser conceptualization.
Critical appraisal guided induction and abstraction, facilitating data transformation from concrete individual study findings to new knowledge and comprehensive results. The answers to the analytic questions are synthesized through comparing and reducing the data. In the ethical sensitivity study, a large (6 foot by 8 foot) paper matrix was constructed with the analytic questions forming rows and individual disciplines forming columns. Arranging the data to be viewed as a whole facilitated the process of synthesizing results. Characteristics of the data were compared to help describe their relationships. Overarching themes, hypotheses, and conclusions about the concept were generated and explored by moving between description and verification of possibilities. Results were confirmed by returning to the original data set, thereby enhancing rigor and validity of results.
BOX 21.1. ANALYTIC QUESTIONS USED IN CONCEPT ANALYSIS OF ETHICAL SENSITIVITY
Nature of Ethical Sensitivity
1. Is ethical sensitivity applied in all practice situations or just in particular ones?
2. Does ethical sensitivity have a futuristic or anticipatory function or does it emerge only within ongoing dilemmas?
3. Are there variations in types of ethical sensitivity? Is ethical sensitivity graduated (e.g., continuum from low to high) or absolute (e.g., present or absent in particular situations)?
4. Does the nature of ethical sensitivity change with the level of the professional’s involvement in the situation (e.g., if the professional is an observer or an actor in the setting)? Can a professional have ethical sensitivity if it does not translate into an action or behavior?
5. Is ethical sensitivity innate or acquired?
6. What is the relationship between technical competency and ethical sensitivity (e.g., Must a professional be competent to be ethically sensitive? Can a professional be ethically sensitive without being competent? Could a physician be able to recognize ethical content in an accounting situation?)
Ethical Requirements for Praxis
7. What personal and interpersonal characteristics are required for developing ethical sensitivity in professional and interdisciplinary praxis?
8. Do employing organizations foster ethical sensitivity?
Preparation for Professional Practice
9. Assuming that ethical sensitivity or at least some aspect of it can be taught or learned, what if any strategies best prepare professionals to develop ethical sensitivity?