J7ournal of medical ethics 1994; 20: 101-107

Modifying autonomy - a concept groundedin nurses' experiences of moral decision-making in psychiatric practiceKim Lutzen and Conny Nordin Huddinge University Hospital, Sweden

Authors' abstractFourteen experienced psychiatric nurses participated in apilot study aimed at describing the experiential aspect ofmaking decisions for the patient. In-depth interviewsfocused on conflicts, were transcribed, coded, andcategorized according to the Grounded Theory method.The theoretical construct, 'modifying autonomy' and itsdimensions, such as being aware of the patient'svulnerability, caringfor and caring about the patient,were identified. The findings in this study make clearthe needforfurther research into the experiential aspectof ethical decision-making in psychiatric practice.

Introduction and purposeThe psychiatric patient is in a vulnerable positionsince mental illness impairs the capacity tounderstand, reason, choose, or act (1,2). The healthcare worker who is professionally obligated to care,has, when caring for such a person, metaphoricallyspeaking, the life of another person in his or herhands (3). Thus, finding ways to respond to theneeds of a patient without threatening his or herintegrity can be conceived as a moral issue. Althoughdecisions concerning the 'right' medical treatment ofmental illness must be based on professional codesof ethics (4), it may not always be possible to makedecisions pertaining to 'good' nursing care on thebasis of rules and regulations (5). All health careprofessionals are either directly accountable orindirectly involved in making or carrying outdecisions in the patient's best interest. The nurse, bynature of her close proximity to, and therapeuticinvolvement with, the patient, is often confronted byproblematic moral issues where she is personallyaccountable for decisions made on behalf of thepatient.

In an earlier theory-generating study (5), aimed atexploring the meaning of the nurse-patientrelationship as perceived by nurses in a psychiatricsetting, the role of 'moral sensing', a type of

Key wordsAutonomy; moral decision-making; psychiatric ethics;nursing ethics; modifying autonomy.

sensitivity to, and awareness of, actions which limitthe patient's self-choice and threaten his or herintegrity, was identified. In that study, the nursesperceived that the main conflict involved main-taining the patient's trust while at the same timecarrying out actions which were not made on thebasis of the patient's self-choice.The purpose of the present study, based on

nurses' experiences of conflicts involving the nurse-patient relationship, was to gain a deeper know-ledge of the nature of moral decision-making asexperienced by nurses in psychiatric settings. Itshould be pointed out that our intention was not toidentify typical situations, but rather to identify anddescribe commonalities in ways of thinking anddealing with difficult decision-making. The focuswas on situations where the patient was not certified.The research method used was a naturalistic

'grounded theory' approach (6,7). In brief, thismethod uses in-depth interviews and observations inthe natural setting for the purpose of developinginductively derived categories that conceptualize aparticular social or interpersonal phenomenon. Themain strategy of 'constant comparative analysis'entails the systematic and simultaneous collectionand analysis of data grounded in empirical reality.One of the benefits in using a grounded theoryapproach is that it provides a structure for collection,coding and categorizing of data. Another feature ofgrounded theory is that the purpose of the literaturereview is to promote 'theoretical sensitivity', ie, todelineate pertinent research questions about thephenomenon of interest and to serve as a source ofdata (6,7).

Review of literatureThe literature shows that Kohlberg's (8) theory ofmoral judgement and moral development haspredominantly been applied in research focused onmoral decision-making in nursing (9,10). Central toKohlberg's theory is that an individual's level ofmoral development is sequential and consistent withage and level of education. The highest level ofmoral reasoning, from the perspective of cognitivedevelopment, is characterized by impartiality and

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102 Modifying autonomy - a conceptgrounded in nurses' experiences ofmoral decision-making in psychiatric practice

the use of universal principles. In research, aperson's level of moral reasoning is determined bythe use of hypothetical situations and follow-upquestions. According to Kohlberg, the theory ofmoral cognitive processes can be universally appliedirrespective of context, and of the person's culture orgender. Moreover, a person's moral thought ispresumed to dictate his or her moral behaviour (8).

Research on nurses' moral reasoning, based onKohlberg's model, has revealed that nursessometimes do not obtain the expected score (9). Inone study, for example, it was found that the nurses'years of experience were related negatively to moralreasoning (10). How can these low scores beexplained? One explanation is that nursing experi-ence may increase the use of context in moralreasoning. Contextualism, or sensitivity to details ofa particular situation, according to Kohlberg, limitsa person's ability to apply universal principles, andas such, exists at a lower level of moral reasoning (8).A contrasting view is that moral problems areembedded in a contextual frame and that bothexperience and contextual sensitivity are necessaryin order to understand the complexities that moralissues entail (11,12). In nursing, experience isgained when the nurse's understanding of a situationalters and when he or she learns to recognize thatsalient ethical distinctions are present, in practice,with each particular patient and his or her family(13).A context-sensitive approach to moral commit-

ment may also be the consequence of nursingeducation, because many nursing programmesemphasize the need for contextual knowledge (aswell as the application of theory and principles) inorder that nurses give individualized nursing care(13). Thus, ethical comportment in nursing isviewed from an experiential perspective, meaningthat moral reflection originates in the clinicalcontext.

Contemporary ethical issues in the practice ofmedicine and nursing seem to have kindled a needfor an ethics grounded in personal relationships andcontext as a complement to abstract and objectivemodels for solving medical (and nursing) issues,especially in psychiatric practice. Pellegrino andThomasma, for example (14), argue for a newconceptual framework for medical ethics thatincludes aspects such as 'compassion' and 'doing foranother what he cannot do for himself because ofillness'. From this perspective, medicine is viewednot only as a science, but also as a value-ladenpractice, involving personal relationships. The claimthat 'health and virtue are fundamental aspirationsofhuman beings', means that the moral enterprise ofhealth care need to develop a theory of ethics that isbased on the realities of everyday practice.More recently, the morality of care and

responsibility, introduced by Gilligan (11,12) andNoddings (15), has served as an alternative to

Kohlberg's approach to ethics. Nurse theorists suchas Nokes (10), Sarvimaki (16), Watson and Ray(17), and Benner (13) have also defined the conceptof care in terms of moral value. The relevance of acaring ethics for nursing seems to rest on theemphasis on interpersonal relationships and context.However, an ethics based exclusively on care canalso be challenged because it rejects the need tosubject moral decisions to the 'scrutiny of universalreason' (18). The various views on how a frameworkfor nursing ethics should be conceived, demonstratethe need for an inclusive rather than a reductionistmodel.

Thus, the sensitizing research questions for thispresent study have been drawn from the perspectivethat the interpersonal nature of psychiatric nursingcalls for a research approach that allows for theillumination of experiential aspects of moraldecision-making. This approach is congruent with aphenomenological view of ethics (3,19,20) Thefollowing questions initiated the research process:

* How do psychiatric nurses experience makingdecisions for the patient?* Within the context of the nurse-patient relation-ship, how do psychiatric nurses perceive andrespond to the needs of the patient?* Can a naturalistic research approach increaseknowledge of the experiential aspect of moraldecision-making?

ProcedureSample: In order to obtain rich verbal descriptions,participants were purposively selected, on the basisoftwo main criteria: more than five years' experiencein the field of psychiatry, and willingness to sharetheir experiences. The nurses who participated weresuggested by nurses known to one of the authors(KL). The participants were described, by thesenurses, as reflective and competent psychiatricnurses. Fourteen nurses, three men and elevenwomen, all with advanced education in psychiatricnursing and more than five years' experience in thisarea, comprised the sample. Four nurses wereemployed in community psychiatry and ten inhospital settings. Information about the study wasgiven and confidentiality was assured. The study wasapproved by the hospital ethics committees inGothenburg and Huddinge, Sweden.Data coliection: Data were obtained from the

transcriptions of audiotaped interviews, which weremost often conducted in the clinical setting andlasted one to two hours. Theoretical memos,containing the results of inductive and deductivethinking about potentially relevant categories andtheir dimensions were kept. Hypothetical questionswere raised during the analysis of transcripts andmemos. These were tested in each successiveinterview. This means that emerging concepts could

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Kim Lutzen and Conny Nordin 103

be verified by comparing the primary data, ie, thenurses' stories, and by seeking support in relevantliterature.

Interview approach: Each interview began withone of us (KL) asking the respondent to describe asituation in which she had to make a decision aboutpatient care but was unsure about the right action. Inorder not to bias the nurses, the main researcher(KL) avoided use of terminology connected to ethicsand to moral concepts. As the nurses themselvesbegan to describe their experiences in moral terms,more specific questions were posed, regarding theirways of experiencing the moral conflict. Anexample of this type of question is: 'When youweighed the different alternatives, what was yourmain concern?'Concept development: The ethnograph, a

computer programme designed for qualitative data-analysis, was used for the first and second level ofanalysis, commencing with the first transcript. Thefirst level of analysis consisted of open coding, theprocess of identifying and comparing substantivecodes. These codes were then subsumed intobroader concepts (6). At the third level of analysis,'modifying autonomy' was identified as a theoreticalconstruct or core category. This category continuedto be compared in each successive interview untilsaturation (completeness of all levels of codes whenno new conceptual information is available), wasachieved in the last interview (6). Some examplesfrom the interviews will be given below to illuminatethe concepts derived.

FindingsMODIFYING AUTONOMYThe emerging theme or theoretical construct,'modifying autonomy' provided a conceptualframework for interpretation of the experientialaspect of model decision-making. Selective samplingof the literature supported this construct as well asidentification of its dimensions, namely being awareof the patient's vulnerability, caring for and caringabout the patient.

'Modifying autonomy' is defined as adjusting themeaning of self-choice to suit the perceived needs ofa patient when there is a conflict. In practice, thiscould entail enhancing as well as limiting thepatient's self-choice. In this study, however, thenurses' descriptions revealed actions which wereinterpreted as limiting self-choice, for example,making decisions without the patient's knowledge,persuading, manipulating the patient's choice andtaking over personal hygiene. It should be pointedout, that in this study, modifying autonomy isdefined according to the meaning of autonomythe nurses themselves implicitly and explicitlyexpressed, ie, self-choice. This definition isunderstood as distinct from coercing, by which wemean threatening the patient with undesirable

consequences if he or she does not go along with adecision. Further, 'modifying autonomy' is neitherthe same as informed consent, which implies shareddecision-making (21), nor the same as self-sufficiency, defined as 'independence and separationfrom others' (22).

BEING AWARE OF THE PATIENT'S VULNERABILITYTo be vulnerable is to be exposed to the will andchoice of others (3). The dimension, 'being aware ofthe patient's vulnerability' describes the interactionbetween the patient's vulnerability and the nurse'sawareness of the implication of this. The nurserecognizes that being in a vulnerable position alsorestricts the patient's range of choices. The nurseplaces an importance on self-choice, in a moral, aswell as a therapeutic, sense. At the same time sheperceives that the patient is in need of protection.The nurse interprets the patient's behaviour, forexample, as not being based on a rational choice.Therefore, in order to maintain the patient's self-esteem or to protect him or her from harm, the nursetakes over the patient's self-choice, in other words,modifies his or her autonomy.

Expressions such as 'not infringing on thepatient's privacy', 'preventing loss of dignity','helping the patient to communicate his needs', 'thepatient's life was in my hands' and 'not wanting tobreach his trust' provided indications of the nurse'sawareness that the patient's welfare could be alteredby her actions. An example of being aware of thepatient's vulnerable position is provided by thefollowing statement:

'This experience made me think in new ways aboutthe meaning of my work. I see myself more clearlynow as being on the patient's side, against what isoften a huge, insensitive health care system servingits own purpose in which the patients can reallycome to be badly treated'.

The relationship between anticipating the patient'sneeds and vulnerability is exemplified by thefollowing account:

'A fifty-year-old man, of another nationality, came tothe clinic in a crisis. His wife wanted a separationand this meant that he was forced to move from theirapartment and to leave their two children. He was ina panic state and could not see clearly why his wifewould do this. His dignity as a person was infringed.He was agitated, desperate and repeatedly said hewas going to kill himself'.

As it was told by the nurse, the patient in the aboveexample came to the nurse for help and advice, thusa dependent relationship was established. Thepatient asked not only for help to deal with his crisis,but also exhibited self-destructive and irrationalbehaviour. The nurse understood this and was aware

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of the consequences of alternative actions. Her mainconcern was how best to respond to the patient'svulnerability: 'How can I protect the patient fromharm without violating his trust in me and hisdignity?'The relationship between 'trust' and 'vulner-

ability' is described in another situation:

'A man who had recently been a patient turned up atthe clinic. He was paranoid and I began to beconcerned for his and his son's welfare. He had hithis son before, and I decided to make a home visit.When I got there, I saw how the place looked andunderstood that he needed to be admitted. Myproblem was, if I went behind his back and reportedto the doctor, it would be a blow to his identity. Onthe other hand, if I didn't, there was a risk that hisson would be harmed'.

In the above context the nurse senses thevulnerability of the patient through observing andthus understanding his circumstances. She is, awarethat her choice of action may breach the principle oftrust and also reinforce the patient's loss of self-choice. The nurse was aware of the patient'svulnerability, even when she entered his home, aprivate sphere, but she felt motivated to do thisbecause she felt she bore some responsibility for hisand his son's safety.

A language problemIn another example, the nurse responds to apatient's being vulnerable by virtue of a languageproblem:

'A young patient from another country wasadmitted to our ward with the diagnosis manicpsychosis. None of us staff believed she waspsychotic. The only one who did was the new andinexperienced doctor, who wanted to follow therule book and give her an injection of haloperidol,by force if necessary. His superior had diagnosedher after seeing her very upset in the emergencyroom where she had been accompanied by herhusband. The woman had only lived in thiscountry three years, she didn't know the languageand was completely isolated. In my opinion shewas in a crisis. I couldn't go through with givingher an injection against her will. It was morallywrong'.

An awareness that it may not always be possible fora patient's own wishes to be met was also made clearby another nurse:

'I know that in order for the ward to function therehave to be limits, but if I were a patient I would bemad, scream and kick if I couldn't make a cup of teawhen I wanted one'.

The nurse in the above situation, put herself in thepatient's position and could in this way understandthe patient's vulnerability. As with all the nurses inthis study, sensitivity to the patient's needs seemedto be based more on human feelings and less onprincipled thinking.

CARING FOR - CARING ABOUTWhen the nurses' ways of responding to the patientsin each described situation was compared, twosenses of 'care' emerged: caring about and caringfor, which can be related to ways of modifyingautonomy. for example, in what follows, caringabout a patient is reflected by the nurse'sspontaneous action. That is to say, she responds tothe patient's vulnerability not out of a sense of duty,but out of a genuine, positive feeling towards thepatient:

'We decided that we would bathe the patient. Therewere two of us and we began by holding her so thatshe couldn't scratch or hit us. We took off herclothes and she just stood there. I thought: "Is thisright? How much is this harming her?" ... When wewere finished I stroked her on the cheek and helpedher with her hair'.

By asking 'how much is this harming her', the nurseindicated an understanding of how the patient mayhave experienced being forced to bathe. This alsoindicates that the nurse's question is based more onfeelings and less on principles or rules. By 'strokingher cheek', the nurse expressed in action thesefeelings.

Moral decisions that seemed to emerge from asense of professional duty and obligation emerged ascaring for. An example of maintaining theprofessional duty to care for was expressed by thefollowing nurse, in response to a patient who did notwant to take her medication:

'When the patient came to me and said she didn'twant any injections I told her that was not my area,it was the responsibility of the psychiatrist to answerquestions concerning medication, ... and that myresponsibility as a nurse was only to evaluate theneed for additional medication'.

The moral commitment to care 'for' and 'about'patients, seems to lead to a dual and conflictingloyalty towards the patient on the one hand and thephysician on the other. This problem is made clearin the following:

'It is the physician who restricts the patient's self-choice, not only in terms of injections, but also interms of orders, such as those which restrict outsideprivileges. The problem is, I'm the one responsiblefor carrying out these orders, even if I don't agreewith them'.

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DiscussionThe aim of this study was to describe the livedexperiences of moral decision-making in psychiatricnursing. As the examples make plain, even patientswho seek psychiatric help on a voluntary basis, areprimarily dependent on the nurse for their dailypersonal care and preservation of dignity. Withinthis framework, moral decision-making can beviewed as an interpersonal phenomenon.The experiences described by the nurses in this

study focus on situations in which they arecompelled to act on behalf of the patient. 'Modifyingautonomy', conceptualizes the nurses' struggles toadjust the principle of self-choice to fit the situationon hand. In all of the described situations, the nursesperceived a threat to the patient's safety or well-being and took measures to prevent harm fromcoming to him or her. This meant that the patient'sself-choice was restricted.

Catalyst for caringThe obligations of nurses as well as physicians havetraditionally been understood in terms of aprofessional commitment to the principle of ben-eficence as well as to the principle of autonomy. Theprinciple of beneficence provides justification foractions which decrease the patient's autonomy (21).In psychiatry, the infringement of a patient's freedomof action may be justified if it will benefit the patientand is consistent with existing medical knowledgeand prevailing norms and values (23). Compared tojustifying making decisions for a certified patient,who lacks the mental capacity for rational self-choice,it may be more difficult ethically to justify taking overa non-certified patient's self-choice. The nurses inthis study seemed sensitive to this problem.The dimension of being aware of the patient's

vulnerable position, may have to do with the nurses'sense of connection, involving transpersonalexperiences and feelings, which may act as a catalystfor caring (24). Psychiatric nursing staff have to dealwith the need to be aware of patients' loss of privacy,helplessness, and at times dignity, and their totaldependency on others for basic needs. An under-standing of the connection between patients' vulner-ability and their limited self-choice may be learnedthrough experience. All of the nurses in this studyhad long experience in psychiatry, which may havesharpened their awareness of the consequences oflimiting or enhancing the patients' autonomy.

However, it is not always clear what conditions,with the exception of conditions stipulated by theDeclaration of Hawaii, must be met before self-choice can be overridden by the principle ofbeneficence. Moreover, it cannot be presumed thatall nursing actions based on 'good' intentions are'right' ethically.The nurses in this study did not seem to begin

their point of moral reflection by referring to

professional codes of ethics or to autonomy as anethical principle. Rather, it was the context of thenurse-patient relationship, involving response andresponsibility, rather than principles, that deter-mined the nurses' definition of self-choice. In thisstudy, the nurses' actions were motivated by 'notwanting harm to come to the patient' and 'doinggood'. This indicates that psychiatric nurses'interpretation of the psychiatric patient's 'right' andtheir knowledge of formal codes of ethics needs to befurther investigated.The findings of this study suggest there is a need

for further thought about the meaning of moralcategories such as vulnerability, self-choice and care,and about how these relate to concrete experiencesin psychiatry as well as in other settings. The inter-relating of concepts such as 'safety', 'well-being','best-interest' and 'autonomy' needs to be furtherexplored in other contexts, especially, how theseconcepts and the way they inter-relate are related tothe two senses of care.One of the limitations of this research was that the

participants were selected on the basis of theircompetency. This raises questions about thegeneralizability of the findings. However, futureresearch could, for example, study how the conceptsidentified in this study work in a hypothesis-testingdesign, using a larger sample. It would be interestingto explore moral decision-making in psychiatry,using for example, different staff categories withvarious educational backgrounds and in differentclinical settings.

Naturalistic research has its advantages in that itcan explore in depth lived experiences, especiallyethical issues, not readily penetrated by othermethods. Yet, a problem with using interviews inresearch is that the expressed moral thoughts andfeelings may not reflect 'true' experiences, sincetime, reflection and awareness of prevailing normsmay have served as a filter. There may be a naturalreservation about exposing 'true' personal feelingsand values to researchers. Triangulation of data(25), ie the use of a variety of methods to collect dataon the same concept, may confirm the accuracy ofconcepts derived in this present study. It may also beof interest to focus on specific situations involvingthe balance between self-choice and beneficence inorder to determine whether both concepts can beretained, rather than one giving way totally to theother.

Institutional restraintsIn psychiatry, autonomy is an important concept,however, its application in research is complicatedby the various definitions that abound in theliterature. For example, autonomy defined aspersonal freedom of choice, without coercion ormanipulation, is central to Kantian ethics (26). Thissomewhat restricted interpretation, if applied in the

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106 Modifying autonomy - a concept grounded in nurses' experiences ofmoral decision-making in psychiatric practice

psychiatric setting, could have different undertonesifwe take autonomy to mean independence and self-sufficiency. Furthermore, defining autonomy fromthe perspective of self-sufficiency seems tocontradict the interpersonal and caring nature ofnursing.The concept of autonomy, understood as 'self-

choice', when applied in health care ethics, raisesadditional questions about whether nurses perceivethemselves as autonomous in moral decision-making. Worth considering is Pellegrino's comment:'the moral obligations of a health professional to hispatient care are complicated by the superimpositionof the moral agency of the team as a team' (14). Forexample, nurses may be caught in between thephysician's authority and the patient's demands, andthus may not experience themselves as morallyautonomous team members. It could be thatinstitutional restraints and medical authority preventthe nurse having freedom of action, ie, prevent herfrom making unforced choices (27).

Although it was beyond the scope of this study, afuture study aimed at examining nurses' autonomyin moral decision-making in relationship to otherprofessional groups within the psychiatric team mayuncover other dimensions of psychiatric nursingethics.The two senses of caring that emerged in this

study reflect the broad spectrum of professionalnursing, which includes response and receptivity,and interdependency, as well as commitment torules and regulations. The sense of care that is basedon deeper feelings has been defined by Montgomery(24) as spiritual transcendence; a definition whichemphasizes connection and the aesthetic form ofcaring. The two senses of care identified in this studycan be compared to Shogan's (28) distinctionbetween caring for and caring about: caring fordescribes the person's conscientious reflection andprofessional obligation to do that which is morallyright. Caring about, is defined as a genuinemotivation to do that which is right, independent ofrules and regulations.

However, it is important that a theoreticaldistinction between caring for and caring about isviewed with caution. Everchanging contexts placedifferent demands on the nurse in the execution ofcare. While caring for can be interpreted as reflectinginstrumental care, based on professional obligations,and caring about, genuineness, based on a naturalmotivation to care, these two senses of care may beequally morally right, depending on the particularcontext.The nurse's focus on finding ways to respond to

the patient's vulnerability was also expressed as themain moral question for the women that Gilliganinterviewed (1 1). Specifically: 'How shall I respondto the needs of the other' is a main moral concern forwomen in an ethics of care (1 1,12,15). However, thethree men included in this study showed similar

concerns, which implies that responding to theneeds of another in professional caring is more amatter of personal commitment to nursing and notso much a gender issue.Many questions can be raised as to the

consequences of caring about a patient too much,since the argument: 'I acted in the best interest of thepatient', obviously, cannot always be sustained.What are the moral consequences of the extreme ofcaring about? Is there not a risk for professionalincompetency when heroic actions take over?

In conclusion, the ability to weigh the principle ofself-choice against beneficence by perceiving, ie,seeing, feeling and understanding the needs andwishes of the person being cared for, should beviewed as a fundamental moral responsibility inhealth care ethics.

Kim Lutzen, PhD, RN, is a doctoral candidate in theDepartment ofPsychiatry at the Karolinska Institute, HuddingeUniversity Hospital, Sweden. Conny Nordin, MD, is AssociateProfessor in the same Department of Psychiatry.

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Veatch R, ed. Medical ethics. Boston: Jones andBartlett, 1988.

(2) Barker P, Baldwin S. Ethical issues in mental health.London: Chapman and Hall, 1991.

(3) Logstrup K. The ethical demand. Philadelphia:Fortress Press, 1971.

(4) Declaration of Hawaii. World Psychiatric Assembly,1977.

(5) Lutzen K. Moral sense and ideological conflict,aspects of the therapeutic relationship in psychiatricnursing. Scandinavian journal of cardiac science 1990;4, 2: 69-76.

(6) Glaser B, Strauss A. The discovery of grounded theory.New York: Aldine de Gruyter, 1967.

(7) Strauss A, Corbin J. Basics of qualitative research.Newbury Park: Sage, 1990.

(8) Kohlberg L. Moral stages and moralization: thecognitive developmental approach. In: Lickona T, ed.Moral development and behavior: theory research and socialissues. New York: Holt, Rinehart and Winston, 1976.

(9) Ketefian S. Moral reasoning and ethical practice innursing, an integrative review. New York: NationalLeague for Nursing, 1988.

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(13) Benner P. The role of experience, narrative, andcommunity in skilled ethical comportment. Advancesin nursing sciences 1991; 14, 2: 1-21.

(14) Pellegrino E, Thomasma D. A philosophical basis ofmedical practice. New York: Oxford University Press,1981.

(15) Noddings N. Caring, a feminine approach to ethics andmoral education. Berkeley: University of CaliforniaPress, 1984.

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(16) Sarvimaki A. Nursing care as a moral, practical,communicative and creative activity. Journal ofadvances in nursing 1988; 13: 462-467.

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(18) Nelson H. Against caring. The journal of clinical ethics.1992; Spring: 8-15.

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(22) Cooper M. Reconceptualizing nursing ethics. Scholarlyinquiry for nursing practice 1990; 4, 3: 209-217.

(23) Tranoy K. Tvang-autonomi; etik i psykiatri. In:Tranoy K. Tvdng-autonomi-etik. Stockholm, Sweden:Socialstyrelsen, 1991: 19.

(24) Montgomery C. The spiritual connection: nurses'perceptions of the experience of caring. In: Gout D,ed. The presence of caring. New York: NLN publi-cations, 1992.

(25) Morse J. Qualitative nursing research. Newbury Park:Sage, 1991.

(26) Kant I. Grounding for the metaphysics of morals,(1785). Indianapolis: Hackett Publishing Company,1981.

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News and notes

Outcomes into Clinical Practice

This conference, organised by the BMA, BMJ and UKClearing House on Health Economics, will be held on7th June 1994 at the International Hotel, Marsh Wall,Docklands, London. It will explore the opportunitiesfor outcome assessment in clinical practice: sharingexamples of good practice.

Parallel Sessions held by expert speakers will include

discussions on: using outcome information to improvecare; purchasing outcomes; and dicing with death rates.The meeting is particularly geared to clinical teams in

both hospital and general practice. For further detailsplease contact: Pru Walters, BMA House, TavistockSquare, London WC 1H 9JP, Telephone: 071-3836518.

News and notes

Ethics of Health Care courseThe Postgraduate Diploma and MA in the Ethics ofHealth Care offered at the University of Kent atCanterbury is intended to be of particular interest tohealth care professionals but is open to anyone with theappropriate qualifications.Work for the postgraduate diploma consists of three

courses: Life and death; Autonomy, power andresponsibility, and Health, needs and entitlements.MA students will also write a dissertation.For further information and application forms write

to: The Graduate Office, The Registry, The Universityof Kent, Canterbury, Kent CT2 7NZ, England.

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