Abstract
As supported by extensive literature, nurses have a role to play in helping patients and families in getting their needs understood and met. This ethical responsibility includes decisions made by nurses in the context of end-of-life care. Ethical decision making is known to be influenced by nurses' understanding of their professional accountability and several cognitive processes that underlie moral action. Rest theorized these processes as moral sensitivity, judgment, moral motivation, and moral character (Moral Development: Advances in Research and Theory; New York: Praeger; 1986). However, few instruments have been developed to understand nurses' ethical decision making during end-of-life care, and most have focused on a single dimension rather than on the multidimensional process. The purposes of this methodological study were (1) to develop a scale with content domains and items capable of describing Korean nurses' ethical decision making at the end of life and (2) to evaluate the scale's psychometric properties using Korean nurses (N = 230). The criteria for participation were Korean nurses having more than 2 years of clinical experience in the types of units where most Korean patients spend the end of their lives: critical care, general medical surgical, and hospice units. The process followed two steps. Phase 1 consisted of the development of domains and items. Three domains were identified through themes derived from an integrated review of relevant literature and the findings from a preliminary qualitative study involving experts in end-of-life care in Korea. Ninety-five items were generated within these three domains. Content validation was completed by a panel of six nursing ethics experts: three in Korea and three in the United States. Next, a pilot study to test readability was conducted using three Korean nurses. During Phase 2, 67 items of the nurses' Ethical Decision Making Around End-of-Life-Care Scale version 3.0 were tested. After item analysis and factor analysis, a 55-item final version of the nurses' Ethical Decision Making Around End-of-Life-Care was established. The total scale and three subscales reported good reliability and validity. The three subscales were labeled "perceived professional accountability," "moral reasoning and moral agency," and "moral practice at the end of life."