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J Med Ethics. 2007 September; 33(9): 508–513.
PMCID: PMC2598191

A dynamic model of ethical reasoning in speech pathology

Abstract

Ten new graduate speech pathologists recounted their experiences in managing workplace ethical dilemmas in semi‐structured interviews. Their stories were analysed for elements that described the nature and management of the ethical dilemmas. Ethical reasoning themes were generated to reflect the participants' approaches to managing these dilemmas. Finally, a conceptual model, the Dynamic Model of Ethical Reasoning, was developed. This model incorporates the elements of awareness, independent problem solving, supported problem solving, and decision and outcome evaluation. Features of the model demonstrate the complexity of ethical reasoning and the challenges that new graduates encounter when managing ethical dilemmas. The results have implications for preparing new graduates to manage ethical dilemmas in the workplace.

Keywords: ethics, speech pathology

New graduates require preparation to manage ethical issues and to facilitate the development of ethical reasoning skills. Buie's 1997 survey of speech pathologists and audiologists found that they experienced a range of ethical dilemmas that included managing unethical behaviour by colleagues, clients disagreeing with intervention approaches, difficulties in assigning treatment priorities, inadequate supervision and training, and external constraints on clinical decision making.1 Effective preparation must equip graduates with the skills to resolve the current ethical dilemmas that confront the profession and the new ethical dilemmas that will emerge during their professional careers. This is important as the nature of ethical dilemmas experienced by professionals may change in response to political, economic and social environments.2

There are many factors that influence how new graduates learn to manage ethical dilemmas. Graduates usually enter their professions equipped with a background of ethical theory and practice with bioethical case studies. Additionally they may make use of their personal and professional values.3 They also have knowledge of their professional code of ethics and have opportunities to develop ethical reasoning skills as they observe the ethical practice of more experienced colleagues.4 The cognitive, personal and perceptual characteristics of new graduates may also affect their skills and motivation to manage ethical issues at work.5,6 It is important that professional preparation programmes, professional associations and allied health managers have knowledge of and enhance the ethical reasoning skills of new graduates to protect the wellbeing of clients, colleagues and the profession. However, it is difficult to propose strategies for supporting and improving ethical management as there is no research investigating how new graduate health professionals approach the task of solving ethical dilemmas. The aim of this study was to investigate the ethical reasoning approaches adopted by new graduates.

METHODS

Participants

Ten participants were recruited from within an area health service in New South Wales. The participants were speech pathologists with 1–18 months' professional experience with diverse caseloads. A summary of their experience and workplaces is presented in table 11.

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Table 1 Professional experience of participants

Data collection

The primary investigator and a research assistant conducted a semi‐structured interview with each participant at work and recorded this on audio tape. The investigators adopted a narrative inquiry approach whereby participants were asked to describe ethical dilemmas experienced at work and their strategies for managing these.6

Data analysis

The primary investigator was responsible for the analysis of the participants' reports. The interpretive process used required several stages of analysis: identification of meaning, configuration of data into a plot and synthesis to provide new insights into the ethical reasoning of new graduates. The participants' narratives were organised into four broad elements of ethical reasoning: identification, problem solving, decision, and outcome.7

Firstly, the dilemma was identified. This included participants' descriptions of one or more ethical dilemmas that they had experienced at work. The problem‐solving element incorporated thoughts, feelings and actions that influenced participants' decision making. The decision element represented the results of ethical reasoning—that is, how the ethical dilemma was managed. The outcome element reflected participants' evaluation of the effect of ethical decisions. Secondly, an ethical reasoning story was configured for each participant by identifying themes under the four elements of identification, problem solving, decision and outcome, using the participant's words to reflect approaches to ethical reasoning. Transcripts and ethical stories were viewed and validated by the participants.

Thirdly, ethical reasoning themes were synthesised across participants. Participants experienced a range of ethical dilemmas and demonstrated individual differences in the way that they managed ethical dilemmas. Nevertheless there were patterns and similarities in their approaches to ethical reasoning. Group analysis resulted in the development of a theoretical framework to represent the ethical reasoning processes demonstrated by the participants.

RESULTS AND DISCUSSION

Analysis of the 10 participants' ethical stories revealed elements of ethical reasoning that were shared by them. A conceptual framework was developed to represent the major elements and features of ethical reasoning undertaken by the participants. This framework incorporated elements of awareness, heightened awareness, an initial response, independent and supported problem solving, decisions, and outcome evaluation from managing an ethical dilemma. Although participants shared these elements of ethical reasoning, there were differences in the nature of the ethical dilemmas they experienced in the workplace. Thus, each element incorporated a range of features that reflected the factors that influenced participants' ethical reasoning.

The major elements and features of ethical reasoning undertaken by the participants are presented in the Dynamic Model of Ethical Reasoning (table 22).

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Table 2 The Dynamic Model of Ethical Reasoning

The model is dynamic in nature because participants did not manage their ethical dilemmas in a series of discrete steps but rather as a fluid, interactive reasoning process that incorporated cognitive and psychosocial elements. Table 33 demonstrates the complex process taken by participant 7 to resolve an ethical dilemma. Although the nature and order of the ethical process varied, analysis of the ethical stories revealed that participants consistently moved back and forth between the elements of ethical reasoning. Thus, they integrated knowledge, experience, insights and values as they resolved ethical dilemmas.

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Table 3 The ethical reasoning process of participant 7 (P7)

Elements and features of the Dynamic Model of Ethical Reasoning

Awareness element

Participants discussed the process of identifying ethical issues at work as either gradual or abrupt. Five participants became progressively more concerned about the ethical implications of work practices. Six participants reported being suddenly confronted by an ethical dilemma during interactions with a client or colleague. Thus, features of the awareness element included early concerns, conflict in practice and critical incidents.

Early concerns

Over half the participants described feeling uncomfortable and unprepared to address ethical problems in the workplace. They attributed this uneasiness to a lack of insight into ethical issues. “You are trying to impress as a new grad and trying to deal with it because you basically think that the expectations that are being placed on you, they must be representative of what it is to work” (P8). Three reported feeling so overwhelmed by their new working environment that they had neither the confidence nor the energy to solve ethical dilemmas. “It's just very overwhelming when you come to a workplace like this and it's so shambolic” (P6).

Conflict in practice

As they gained experience, new graduates perceived discrepancies between policies and practice. Six participants noted that the policy of equal access to community services was not effectively implemented with clients, including those from culturally and linguistically diverse backgrounds. “In order to provide a fair and equitable service for all clients, we have an interpreter service available at the hospital. But I guess in terms of an ethical dilemma it can be quite difficult to book those interpreters” (P7).

Critical incidents

Nine participants reported increased sensitivity to ethical issues when clients' wellbeing and safety were at stake. Participants working in hospital settings were frequently involved in decisions to provide nasogastric feeding for adults with swallowing disorders who were unable to maintain adequate oral nutrition. “When I took over this lady she was still inappropriate for oral intake and still hadn't had any kind of nutrition for over a week” (P4). Participants perceived it as their responsibility to ensure that that the client's family and the healthcare team made an informed decision about whether to initiate tube feeding when the prognosis for recovery was poor.

Facilitating awareness

Although participants were able to describe the nature of an ethical dilemma, they were generally unable to define the specific ethical principles at stake. They questioned whether their dilemma was an ethical problem. “I don't know if it's a real ethical dilemma, though” (P3). Managers could support new graduates' awareness of ethical issues by discussing the ethical dilemmas they themselves have experienced, raising ethics during supervisory conferences and identifying ethical issues during case conferences.

Independent problem‐solving element

All participants had engaged in independent problem solving to manage ethical dilemmas. The independent problem‐solving element of the Dynamic Model of Ethical Reasoning has cognitive, emotional and psychosocial features, and incorporates participants' initial reactions, professional responsibility, self‐protection, clinical reasoning, rules, values and beliefs. Most participants sought advice from experienced colleagues to support independent problem solving. A perceived lack of support resulted in new graduates struggling to manage ethical dilemmas independently.

Initial reactions

The first response of seven participants to an ethical dilemma was to question whether it was their problem. “The main thing for me was knowing whether I should get involved or not” (P1). Eight participants described an initial response based on personal values and sympathy for the perceived “victims” of the ethical dilemma. “I just felt really sorry for them and really wanted to give them more services” (P5).

Accepting professional responsibility

All participants reflected upon their professional roles and responsibility to advocate for clients with communication and swallowing disorders. “I feel responsible for them because they are now… these are my children!” (P6). Once participants accepted responsibility for clients' welfare, they adopted an active role in resolving dilemmas or seeking support to improve the quality of client care.

Self‐protection

Seven participants raised concerns about the effects on relationships with colleagues and managers of raising ethical issues or challenging work practices. “You don't want negative feelings or thoughts directed back to you” (P10). Self‐protection influenced participants' motivation to resolve ethical dilemmas. Participants were reluctant to pursue ethical issues if they perceived risks of alienating more senior colleagues. However, they were motivated to resolve ethical dilemmas when they perceived that others held them responsible for the outcome. “You don't want to leave yourself open for litigation” (P2). These results are consistent with Braunack‐Mayer's findings that health professionals' concern for maintaining reputation and status influences their response to ethical dilemmas.8

Clinical reasoning

All participants provided examples of client based dilemmas and demonstrated clinical reasoning skills.9 Participants drew knowledge from previous clinical cases to support decision making “I'd just had another lady go home who was quite similar at the start but the team that this other lady was under had put an NG tube down straight away and she had improved quite markedly” (P4). Given their limited clinical experience, new graduate professionals may benefit from further application of evidence based practice to manage ethical dilemmas rather than relying on limited case experience.

For nine participants, it was important to establish who was to blame for an ethical problem. “I think the organisation fails its clinicians by not having some sort of protocol that is regularly evaluated” (P6). Although an understanding of cause–effect relationships may help new graduates avoid unethical behaviours, a culture of blame may prevent them from seeking support when ethical problems occur in the work place.

Rules

Seven participants reported using policy “rules” to guide ethical problem solving. Participant 10 perceived rules as the means for providing a fair service. “If you rang everyone on that waiting list and asked them for their story they would all have some sort of emotional heart‐wrenching story about why their child needs the service now So, I think that you need the rules” (P10). Following the rules reduced the anxiety of participant 10 about providing limited services to clients. However, a reluctance to challenge rules and policies may perpetuate unethical practices.

Beliefs and values

Eight participants considered attitudes, beliefs and values during problem solving. Participant 2 reflected upon her values when she addressed issues of safety and quality of life with a client. “I would want my mother to be comfortable and enjoy what life that she had left” (P2). They reported conflict between the cognitive and psychosocial features of ethical reasoning when strategies to resolve ethical dilemmas “didn't feel right”. “I obviously had to discharge her because that's the policy and the mother was aware of that…but I just didn't feel that it was right to be not offering that child anything” (P9). It may not be appropriate or possible to change the beliefs and values of new graduates, yet our results support the claims of Schneider and Snell that the opportunity to share and challenge attitudes about ethical issues may facilitate ethical reasoning skills.2

Lack of support

Independent problem solving, according to four participants, resulted when senior colleagues failed to respond to ethical concerns. Participant 8 developed her own strategy for managing missing documentation because she perceived that senior colleagues were reluctant to address a staff member's incompetence. “I would mention to them that all those files were missing, they never really offered strategies in terms of how I can approach it” (P8).

Facilitating independent problem solving

Independent problem solving was a consistent feature of the ethical‐reasoning process and reflected participants' concern for the needs of clients, carers, managers and their professional status. During the dynamic process of ethical reasoning, participants frequently returned to independent problem solving to compare and contrast their thoughts and beliefs with recommendations provided by more experienced professionals. Results from this study suggest that the ethical reasoning of new graduates may be facilitated by reflecting upon the beliefs and values inherent in ethical dilemmas and by discussing roles, responsibilities and boundaries in managing these dilemmas. New graduates may require support to interpret and apply policies and procedures with the flexibility required to meet client and organisational goals.

Supported problem‐solving element

When managing ethical dilemmas, participants sought support from managers, colleagues and sometimes, other new graduates. However, the support they requested varied according to participant and the nature of the ethical dilemma and included features of checking, discussing and handing over problem solving to others.

Checking

Four participants independently resolved ethical dilemmas, then sought support to confirm their ethical decision. “Basically just a bit of reassurance that I was going in the right direction” (P1). Participants usually sought such support from senior professionals.

Discussing

Seven participants reported collaborative problem solving with managers, colleagues or interdisciplinary team members. During these interactions, participants shared their perceptions and suggestions for managing ethical dilemmas. Managers provided a holistic perspective to ethical reasoning and suggested alternative practical strategies for managing ethical dilemmas based on their professional experience. “Talking to a senior and once talking about the different types of options and getting more perspective on the quality of life of this lady” (P2). Participant 2 was able to propose a range of intervention strategies to meet her client's needs. Colleagues and team members provided professional and emotional support by sharing the responsibility for resolving ethical dilemmas. “I actually find the whole team to be very supportive” (P4).

Handing over

Some ethical dilemmas were immediately “handed over” to a senior professional. Three participants reported strong psychosocial responses or feeling disempowered to manage ethical issues. “The safest option for me was to choose not to discuss it with anyone, to refer any comments to [manager]” (P7).

Facilitating supported problem solving

Consistent with the discussion by Handelsman et al of the acculturation process of ethical reasoning, senior clinicians were generally considered to be role models for ethical practice.10 “She's a great model and she's actually quite a bit more senior to me” (P4). Consequently, new graduates need to observe positive role models to develop skills, confidence and independence in ethical reasoning. Similarly, role models who initiate debate of ethical issues and challenge inappropriate work practices and procedures11 may facilitate ethical courage in new graduates.

Decision element

The decision element describes the features of ethical decisions as actions for a client, professional, team or organisation.

Action for client

Participants were motivated to provide the best outcomes for their clients. Nine participants reported that their ethical decision focused on client care. However, they felt restricted to making changes at the micro level of the clinic room rather than at the organisational level. Ethical decision making incorporated an acceptance of current work systems and a motivation to work within these systems to best meet the needs of clients. “Instead of giving her 6 weeks I'm going to see her once a month for 6 months and do a lot of collaboration with school and …give her a home programme as well”(P5).

Action for professional

Participants considered the effect of ethical decisions on their current levels of stress and job satisfaction and their future careers. Seven participants indicated that ethical decisions focused on their own needs. In community health settings, such decisions sometimes resulted from participants' tension between meeting the needs of a large caseload and addressing their own need for client‐free time to pursue professional development activities. “My decision with that has been more to preserve myself” (P10). In hospital settings, participants reported that avoiding litigation was of paramount importance when issues of quality of life versus safety arose in client care. These issues were most likely to occur when the participant was managing a client with swallowing difficulties and conflict arose between providing a “safe” diet and the carer's desire to provide more enjoyable or culturally appropriate meals. “You cannot care for your loved one for the reason that if something does happen one of us or all of us could be in a lot of strife” (P2). Participants empathised with carers' needs to support their family member in hospital and experienced discomfort when they perceived that dietary recommendations were enforced so that the speech pathologist would not be held accountable for any medical complications.

Action for team

Five participants expressed concerns about establishing a professional identity within their workplace teams. When they perceived that a team had disregarded their clinical recommendations, their ethical decisions focused on education and prevention rather than the individual client. “I think it's more of a prevention of it ever happening again. I mean for me the ethic has already been sort of broken” (P3).

Action for the organisation

There were three examples of participants withholding information to reassure clients about services yet save face for their organisations. “I'm always put in a position where I have to cover up all the time” (P6). Participants perceived it to be disloyal to discuss ethical concerns, a potential barrier to accessing support from professionals external to their workplace.

Facilitating ethical decisions

Ethical decisions frequently involved prioritising the needs and wishes of one stakeholder over another. Perhaps this is why six participants had unresolved ethical dilemmas at the time of their interview. New graduates may benefit from support to critically evaluate the needs of clients, colleagues and their employers and thus prioritise these needs when making an ethical decision.

Outcome element

Participants were requested to evaluate the outcomes of their ethical reasoning. In response, they judged the personal and professional outcomes of ethical decisions as positive, negative or adequate.

Positive outcomes

Positive outcomes of ethical reasoning were described by all the participants and included increased confidence in clinical skills and improved satisfaction with client care. “It was just amazing because as soon as she started to improve she had the best chance of happiness” (P4). Improved outcomes for clients included effective service delivery, clients having a “voice” in the healthcare system, or the implementation of quality‐improvement measures at work. “Lots of changes being made, really positive changes” (P8). Five participants experienced a stronger professional identity after defining their professional roles and responsibilities. Three participants developed a framework for managing ethical dilemmas and gained insight into workplace policies and procedures. Participant 9 explained that she had developed a stronger support network as a result of her ethical dilemma and her concerns that there were “no more places to go for help” were overcome.

Negative outcomes

Six participants expressed personal and professional frustration when limited resources prevented the application of evidence based practice. “I've been trained for it. And I can do it, but I can't with the limited services. I guess I feel really frustrated with that” (P5). They raised concerns about the effect of service delivery issues on client outcomes and clinicians' skills.

Adequate outcomes

Usually, participants reported an adequate outcome from managing an ethical dilemma. They recognised that services could be improved but were satisfied with their contribution to client care. “The only thing is knowing that within that length of time I've done everything I could for that child” (P9).

Facilitating outcomes

Participants were generally satisfied with the strategies used to manage ethical dilemmas. New graduates indicated that they fulfilled their professional responsibilities within the limitations imposed by workplace policies. However, seven participants expressed lingering concerns about the long‐term effect of ethical decisions on client care. The provision of a healthcare service in workplaces that are under‐resourced may result in poorer outcomes for clients and increased levels of stress and dissatisfaction for professionals. Providing new graduates with the opportunities and strategies to advocate effectively for clients may facilitate outcomes consistent with ethical practice.

CONCLUSION

The Dynamic Ethical Reasoning Model reflects the complexity of the ethical reasoning of new graduates. The elements and features of the model incorporate processes described in previous models of moral development. They are consistent with propositions that effective ethical reasoning requires sensitivity, problem solving skills, and the motivation and determination to act on decisions.6,12,13,14 Our results indicate that new graduates may experience problems in various elements of the ethical reasoning process. Some struggled to define the nature of an ethical dilemma, others experienced difficulties with problem solving or reaching an ethical decision. By addressing the features of each element of the ethical reasoning process, educators, professional associations and managers may facilitate the development of new graduates' ethical reasoning skills.

The Dynamic Model of Ethical Reasoning is not a prescriptive tool that dictates how to manage ethical dilemmas. It provides scope for supporting new graduates to manage ethical dilemmas in the workforce as it reflects key elements and features of their ethical reasoning. Professional preparation programmes, professional associations and expert clinicians have an important role in equipping new graduates with the knowledge, experience and confidence to identify and manage ethical dilemmas effectively.

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