What are the Major Ethical Issues in Conducting Research? Is there a Conflict between the Research Ethics and the Nature of Nursing?

Abstract

Background: Research ethics involve requirements on daily work, the protection of dignity of subjects and the publication of the information in the research. However, when nurses participate in research they have to cope with three value systems; society; nursing and science which may be in conflict with the values of subjects, communities, and societies and create tensions and dilemmas in nursing. Method and material: Using the Medline and the Nursing Cinahl data base, the most important ethical issues which appear in bibliography, will be addressed. After a short description of the nature of nursing, and the advocacy role of nurses, the writer will attempt to highlight the possible conflicts that nurses have to deal with, when undertaking or participating in research. Results: The major ethical issues in conducting research are: a) Informed consent, b) Beneficence-Do not harm c) Respect for anonymity and confidentiality d) Respect for privacy. However, both the nature of nursing which focuses on caring, preventing harm and protecting dignity and the advocates role of nurses which calls for defending the rights of subjects, are sometimes incongruent with the ethics in research. Conclusions: Ethical issues, conflicting values, and ambiguity in decision making, are recurrently emerging from literature review on nursing research. Because of lack of clarity in ethical standards, nurses must develop an awareness of these issues and an effective framework to deal with problems involving human rights.

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What are the Major Ethical Issues in Conducting Research?
Is there a Conflict between the Research Ethics and the Nature
of Nursing?
Georgia Fouka1, Marianna Mantzorou2
1. RN, PhD, Assistant Professor of Nursing, Department of Nursing Β΄, Technological Educational
Institute (TEI) of Athens, Greece
2. RN, MSc, Lecturer, Department of Nursing Β΄, Technological Educational Institute (TEI) of
Athens, Greece
Abstract
Background: Research ethics involve requirements on daily work, the protection of dignity of
subjects and the publication of the information in the research. However, when nurses
participate in research they have to cope with three value systems; society; nursing and science
which may be in conflict with the values of subjects, communities, and societies and create
tensions and dilemmas in nursing.
Method and material: Using the Medline and the Nursing Cinahl data base, the most important
ethical issues which appear in bibliography, will be addressed. After a short description of the
nature of nursing, and the advocacy role of nurses, the writer will attempt to highlight the
possible conflicts that nurses have to deal with, when undertaking or participating in research.
Results: The major ethical issues in conducting research are: a) Informed consent, b)
Beneficence- Do not harm c) Respect for anonymity and confidentiality d) Respect for privacy.
However, both the nature of nursing which focuses on caring, preventing harm and protecting
dignity and the advocates role of nurses which calls for defending the rights of subjects, are
sometimes incongruent with the ethics in research.
Conclusions: Ethical issues, conflicting values, and ambiguity in decision making, are recurrently
emerging from literature review on nursing research. Because of lack of clarity in ethical
standards, nurses must develop an awareness of these issues and an effective framework to deal
with problems involving human rights.
Keywords: research ethics, moral dilemmas in research, nature of nursing, nursing research,
nursing advocacy
Corresponding author:
Mantzorou Marianna,
13, Tassopoulou str. Ag. Paraskevi, 15342,
Tel. 210 6398958, mobile: 6937849980,
Email: mantzorou@teiath.gr

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Introduction
thics is rooted in the ancient Greek
philosophical inquiry of moral life. It
refers to a system of principles which
can critically change previous considerations
about choices and actions.1 It is said that
ethics is the branch of philosophy which
deals with the dynamics of decision making
concerning what is right and wrong.
Scientific research work, as all human
activities, is governed by individual,
community and social values. Research
ethics involve requirements on daily work,
the protection of dignity of subjects and the
publication of the information in the
research.
However, when nurses participate in
research they have to cope with three value
systems; society; nursing and science. The
societal values about human rights, the
nursing culture based on the ethic of caring
and the researcher's values about scientific
inquiry. According to Clarke these values
may conflict with the values of subjects,
communities, and societies and create
tensions and dilemmas in nursing.3
In this paper, the most important ethical
issues will be addressed. After a short
description of the nature of nursing, and the
advocacy role of nurses, the writer will
attempt to highlight the possible conflicts
that nurses have to deal with, when
undertaking or participating in research.
Historical overview- Ethical codes
Human experimentation has been
conducted even before 18th century.
However, the ethical attitudes of researchers
drawn the interest of society only after
1940's because of human exploitation in
several cases. Professional codes and laws
were introduced since then in order to
prevent scientific abuses of human lives.4
The Nazi experiments led to the Nuremberg
Code (1947) which was the leading code for
all subsequent codes made to protect human
rights in research. This code focuses on
voluntary informed consent, liberty of
withdrawal from research, protection from
physical and mental harm, or suffering and
death. It also emphasises the risk- benefit
balance.5 The only weak point of this code
was the self regulation of researchers which
can be abused in some research studies.4 All
declarations followed, forbade non-
therapeutic research. It was only in 1964
with the declaration of Helsinki that the
need for non therapeutic research was
initiated.6 The declaration emphasised the
protection of subjects in this kind of
research and strongly proclaimed that the
well being of individuals is more important
than scientific and social interests.4
In terms of Nursing the first inquiry was
the "Nightingale Pledge" (1983). Since then
there has been a significant development of
professional codes in conduct and research.
The American Nurses' Association (ANA)
Guidelines for Research, the Human Rights
Guidelines for nurses in clinical and other
research (1985) and the Royal College of
Nursing Code for nurses in research (1977)
provide a strong assistance to professional
nurses as well as reassurance to patients, the
public and society, of professionals’
intentions.7-9
Major ethical issues in conducting research
Informed consent
Informed consent is the major ethical
issue in conducting research. According to
Armiger: "it means that a person knowingly,
voluntarily and intelligently, and in a clear
and manifest way, gives his consent" .10
Informed consent is one of the means by
which a patient's right to autonomy is
protected. Beauchamp and Childress define
autonomy as the ability for self
determination in action according to a
personal plan.11 Informed consent seeks to
incorporate the rights of autonomous
individuals through self- determination. It
also seeks to prevent assaults on the
integrity of the patient and protect personal
liberty and veracity.3 Of course individuals
can make informed decisions in order to
E

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participate in research voluntarily only if
they have information on the possible risks
and benefits of the research.12 Free and
informed consent needs to incorporate an
introduction to the study and its purpose as
well as an explanation about the selection of
the research subjects and the procedures
that will be followed.8 It is essential to
describe any physical harm or discomfort,
any invasion of privacy and any threat to
dignity as well as how the subjects will be
compensated in that case.5 In addition the
subjects need to know any expected benefits
either to the subject or to science by gaining
new knowledge.8 A disclosure of alternatives
is also required as for example in the
Tuskegee study about syphilis. In this study,
rural black men were chosen as subjects in a
study of syphilis. Although a cure for syphilis
was found after the start of the study, it was
decided not to treat them and they had not
been told that penicillin was effective to
their disease.13 The researcher must inform
the subjects about the methods which will
be used to protect anonymity and
confidentiality and indicate a person with
whom they can discuss the study. He must
also provide a "Noncoersive Disclaimer" which
states that participation is voluntary and no
penalties are involved in refusal to
participate.14 Moreover, the subject must be
told that some information has been
deliberately withheld in order to avoid
altered behaviours. The researcher must also
take into account that persons with physical,
cultural and emotional barriers may require
a very simple language in order to
understand him.15 Finally, the freedom to
withdraw must be explained.5 This is very
important but raises the issue of how
difficult the subjects can withdraw after
developing a personal and sometimes
friendly relationship with the researcher.12
With regard to withdrawal a researcher may
be in a dilemma in case many subjects
choose to withdraw at an advanced stage of
the study, because this can affect the
validity of the results. The Declaration of
Helsinki provide some help as it declares that
the interest of the subject must always
prevail over the interests of society and
science.3 According to this, the will of the
subject must be respected at any cost for
the research.
Another major ethical issue is obtaining
an informed consent from groups with
diminished autonomy which will be further
discussed later. From what has been
discussed, it becomes clear that disclosure,
comprehension, competency and
voluntariness are the four essential parts of a
consent.5
Beneficence- Do not harm
The ethical principle of beneficence
refers to the Hippocratic "be of benefit, do
not harm". Beauchamp and Childress, suggest
that
"the principle of beneficence includes
the professional mandate to do effective
and significant research so as to better serve
and promote the welfare of our
constituents".11
Beneficence is sometimes difficult to
predict when creating a hypothesis especially
in qualitative research. Carr says that if the
research findings prove that it was not
beneficial as it s expected, this can raise
immense ethical considerations especially for
nurses.16 Ford and Reutter say that
"beneficence relates to the benefits of the
research, while non-malificence relates to
the potential risks of participation".12 Non-
malificence requires a high level of
sensitivity from the researcher about what
constitutes "harm". According to Burns and
Grove "discomfort and harm can be
physiological, emotional, social and
economic in nature".5
When a researcher tries to learn intimate
details of the participants lives he has to
deal with opening old wounds.12 Non-
malificence dictates both preventing
intentional harm and minimising potential
harm. A researcher must consider all possible
consequences of the research and balance
the risks with proportionate benefit. The
type, degree, and number of potential risks
must be assessed as well as the patients

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value system which ranks various harms.17
The risk benefit ratio can only be achieved
by identifying these factors. If the risks
outweigh the benefits, the study should be
revised.5
Last, debriefing at the end of a study,
should be mentioned. Treece and Treece say
that debriefing refers to explaining the exact
aim of the study and why the disclosure was
not full.18 Treece and Treece suggest that
subjects should feel as much at ease as
possible and express their feelings.18 In
addition, Burns and Grove suggest that if the
subjects experienced a high level of
discomfort, they should be debriefed or
referred to appropriate professional
intervention as necessary.5
Respect for anonymity and confidentiality
The issue of confidentiality and
anonymity is closely connected with the
rights of beneficence, respect for the dignity
and fidelity.3 ANA suggests anonymity is
protected when the subject's identity can
not be linked with personal responses. If the
researcher is not able to promise anonymity
he has to address confidentiality, which is
the management of private information by
the researcher in order to protect the
subject's identity.19 Levine advocates that
confidentiality means that individuals are
free to give and withhold as much
information as they wish to the person they
choose.20 The researcher is responsible to
"maintain confidentiality that goes beyond
ordinary loyalty". Clarke addresses the
ethical dilemma of the researcher when
confidentiality must be broken because of
the moral duty to protect society.3
According to the utilitarian theory, which
focuses on the best interest of all involved,
the happiness of society is of greater
importance. On the other hand, the
deontological theory which ignores the result
implies that the moral duty is what really
matters. If a researcher, though, acts
deontologically he may feel that he has not
protected society. Another issue is that the
researcher may have to report confidential
information to courts which can also cause
moral dilemmas. In that cases it can be
argued that the moral duty and personal
ethos can be stronger than legal
requirements.3 Even if there are no duty
conflicts, the researcher faces several
problems with respect to maintaining
confidentiality especially in qualitative
research where conduct is personal, the
sample is smaller and the reports display
quotations of interviews. Ford and Reutter
suggest using pseudonyms and distorting
identifying details of interviews when
transcribing the tapes used.12
In situations that are particularly
complex, sensitive, and in which the
participants are extremely vulnerable, a
Certificate of Confidentiality issued by the
U.S. Department of Health and Human
Services (DHHS) may be useful to help ensure
the privacy of research participants
especially in studies in which participants
and researchers may be exposed to
compelled legal disclosure of research data.
The researchers must always bear in
mind all psychological and social implications
that a breach of confidentiality may have on
subjects. In order to protect participants,
they have to inform them on their rights, and
use all possible coding systems that they
regard appropriate in each case.
Respect for privacy
The fifth principle of the entitled "A
Patient's Bill of rights" document published in
1975 by the American Hospital Association
(AHA), affirm the patient's right of privacy.21
According to Levine : "privacy is the freedom
an individual has to determine the time,
extent, and general circumstances under
which private information will be shared
with or withheld from others ".20
Kelman believes that an invasion of
privacy happens when private information
such as beliefs, attitudes, opinions and
records, is shared with others, without the
patients knowledge or consent.22 However,
the American Nurses Association says that
different persons may held different opinions
about when privacy is invaded. A researcher
cannot decide on behalf of other persons on

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those delicate issues. All aims, instruments
and methodology must be discussed with the
prospective subject and the research workers
prior to the investigation.
Treece and Treece suggest that
whenever subjects refuse to report personal
information as they regard it an invasion of
privacy, the researcher ought to respect
their views.18 This may even apply to report
of age, income, marital status, and other
details that the subject may regard intimate.
They also imply that privacy can be invaded
when researchers study certain groups
without their knowledge and without
identifying themselves. An example of such a
study that the researcher hid his identity,
was Humphrie's study "Impersonal Sex in
public places" in which, he observed
homosexuals during sexual activities in public
men's rooms.18 Health care practitioners
need to be aware that "an invasion of privacy
may cause loss of dignity, friendship or
employment, or create feelings of anxiety,
guilt, embarrassment or shame".5 In
conclusion, all possible measures have to be
taken in order to protect subjects from
potential physical, psychological or social
damage during the research or after
circulation of the results.8
Vulnerable groups of people
Nowadays, there is an increased concern
about vulnerable groups and whether it is
ethical or not for them to be used as
research subjects." Fisher classifies
vulnerability as one characteristic of people
unable to protect their own rights and
welfare".23 So, vulnerable groups include
captive populations (prisoners,
institutionalised, students etc), mentally ill
persons, aged people, children, critically ill
or dying, poor, with learning disabilities,
sedated or unconscious.
The different opinions about their
participation in research can be attributed to
their inability to give an informed consent
and also to their need for further protection
and sensitivity from the researcher as they
are in a greater risk of being deceived,
threatened or forced to participate. Many
are in favour of the use of such subjects in
research whilst others would argue strongly
against it. Most condition their responses
according to the seriousness of the research,
the level of potential risk and the availability
of alternatives.6 According to Burns and
Grove vulnerability increases the need for
justification for the use of such subjects.5 An
intense analysis of potential risks and
benefits should be the first step of starting
such a research and careful approach should
exist both in acquiring consent and during
the research procedure itself. Persons with
diminished autonomy are also more
vulnerable to invasion of privacy, since their
right to privacy is limited in contrast to
other's right to know. In the case of mentally
ill, family as well as employers and
colleagues have the right to know while
patients may not be able to see the
testimony of others in their own record. In
the case of mentally ill patients, it is
important to measure comprehension and
develop valid tools for it, before obtaining
informed consent to participate in a research
study. In a descriptive study of Beebe and
Smith the Evaluation to Sign Consent (ESC)
form was used in order to document
comprehension in 29 schizophrenia
outpatients.24 Participants living in
supervised housing were significantly more
likely to require prompts than those living
alone. Participants prescribed two
antipsychotic medications were significantly
more likely to require a prompt than those
prescribed only one antipsychotic.
According to Lasagna there are strong
feelings among professionals who disagree
with experimentation on vulnerable groups.25
However, the potential improvement of their
nursing care raises the issue of careful
consideration before rejecting or accepting
this kind of research.
Skills of the researcher
Jameton declares that in research the
three more important elements are the
competency of the researcher, the careful
design, and worthwhile expected
outcomes.13 The Royal College of Nurses

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declares that nurse researchers should have
the necessary skills and knowledge for the
specific investigation to be carried out and
be aware of the limits of personal
competence in research. Any lack of
knowledge in the area under research must
be clearly stated. Inexperienced researchers
should work under qualified supervision
which has to be reviewed by an ethics
committee.26
What is more, careful choice of method
for data collection, to ensure validity and
reliability, are two main requirements that
must be met in all kinds of research. The
choice depends on the object of the study.
When human beings are involved, all the
ethical issues, discussed above, must be
taken into account.2
The nature of Nursing
The nature and essence of nursing
reflects on human beings and their
relationship with health.27 Mckenna states
that the primary scope of nursing is to help
persons to adapt in different stages of illness
which is a rather task-orientated and
behaviouralistic approach.28 On the other
hand, Swanson notes that nursing views
persons as a whole and health as a subjective
and meaningful experience of integrating
with the environment.29 Mckenna views
nursing's main elements as interpersonal
interactions which involve practical actions
but Chinn and Jacobs make hints on holism
as well.28,30 Literature contains diversed
nursing definitions which indicates the
complicate and uncertain nature of it.28
However, most authors reflect on caring as
the most important part of nursing. Raya
focuses on the unique element of caring in
nursing while Swanson views Nursing in the
same scope as "informed caring for the well-
being of others".29,31 The ANA policy
statement declares that "Nurses diagnose and
treat human responses to actual or potential
health problems".8 This is quite indicative of
the nurses' role, but it does not reflect the
values, experience and passion of nursing.
Swanson suggests that nursing has to do with
"science, concern for humanity and caring.29
What exactly does it mean to care?
Mayeroff describes caring as an interaction
which offers space for personal growth for
both the carer and the cared.32 Roach says
that caring describes precious moments
when participants realise their common base
of humanity".33 Burnard and Chapman
suggest that the most important elements of
caring are: "knowledge, alternating rhythms
in relationships and continuous changes in
reactions to others, patience, honesty, trust,
humility, hope and courage".9
In Nursing however, the element of
caring is undervalued because the profession
was viewed as "women’s work" in which, care
is governed by sentiment and not by logic.34
Nursing was perceived by society as an
extension of medicine while curing is
regarded more important than "enhancing
life quality" and preserving human dignity".29
On the other hand, Roach says that the cure-
care dichotomy used to distinguish nursing
from medicine is an artificial one.33
As McNeil et al say, "care is the basis and
precondition of all cure".34 Swanson proposes
a structure for caring which includes
maintaining belief in persons, knowing the
other person, being with, doing for, and
enabling.29 The last two are the most
important parts related to research. Doing
for, means predicting individual needs,
encouraging, performing tasks with adequate
skills and competence, protecting the
patient from harm and preserving the
dignity. On the other hand, enabling, means
enhancing self-care by training, informing
and explaining to the patient as well as
assisting with finding alternatives.29
Leininger supports the thesis that:"there is
no discipline that is so directly and
intimately involved with caring needs and
behaviours than the discipline of Nursing".35
However, caring is not unique in nursing.
Other professions can also claim that caring
is an important part of their practice. It can
not be stated either that all nursing
procedures include caring.29 What is more,
can nursing today be a synonym of caring?
The vulnerability of the sick and the lack of
patient participation in health care, creates
a danger of patient exploitation by nurses.13

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The rapid change and development of
nursing emerged the need for a code of
professional conduct to guide nurses in their
practice.
Advocacy in nursing
Advocacy primarily used in legal
contexts, refers to the protection of human
rights of people who cannot defend them for
themselves.17 The role of nurses as advocates
is closely related to the purpose of nursing,
the nurses views about humans and the
needs of persons in health care.36 In
literature advocacy is described in three
different models: The rights protection
model implies that nurses helps persons to
understand and exercise their rights. They
also aim to protect and enhance personal
autonomy.37 The value based decision model
suggests that nurses should not impose
decisions but assist persons to decide which
choices are most consistent with their
values. They should also support the patients'
confidence in their own decisions and
prevent limitations of their freedom.17 This
model is considered by Gadow in the
"existential advocacy" which focuses on the
clarification and reconsideration of the
values of the patients by self examination.38
According to Fowler and Arrif this thesis is
distinct from both "paternalistic and
consumer rights protection" and declares the
fundamental rights of self determination.17
However according to Johnstone, Gadow
does not provide adequate reasoning why
self-determination is the most important
value or why the human rights claim to self-
determination are quite different from a
patients rights claim to self-determination.
Last, the respect for persons model focuses
on human dignity, privacy and self-
determined choices that the nurse has to
protect if the person is not autonomous or
self-determining.1 Murphy argues that this
model which she calls the advocate model of
the nurse-patient relationship, reflects the
basic value of nursing which is the best
possible care for patients.39 However, nurses
should not be considered as being in a solely
position to act as patients advocates.
According to Johnstone all professions with a
morally significant relationship with a
patient ought to fulfil the role of the
advocate.1 The ANA Code for nurses though,
refers to the nursing role of advocate in
safeguarding the well being of the client and
the society.8 However, both the nature of
nursing which focuses on caring, preventing
harm and protecting dignity and the
advocates role of nurses which calls for
defending the rights of subjects, are
sometimes incongruent with the ethics in
research.
Conflicts in nurses
Beneficence-Non malificence
A common feature in professional
conduct codes and those specific to research
is the principle of non-malificence. The ANA
Code of conduct declares that the nurse
protects the clients and the public from
unethical, incompetent or illegal practice of
any person.8 This statement raises the issue
of advocacy when nurses have to protect
patients from the researchers’ incompetence
or unethical behaviour. Even if nurses are
certain about the incompetence of the
investigator, which is usually very difficult,
they have to deal with serious dilemmas.
First they have to consider the fact that if
patient learn that they are exposed to
professional misconduct, they may lose faith
in health care. Jameton though, believes
that patient should be informed as they will
appreciate the trust shown to him by
frankness.13 If the researcher does not inform
or compensate patient then nurses have to
decide between the duty to safeguard the
well-being of patient and be loyal to them,
and the loyalty to colleagues.
However, even if nurses decide that
their duty of caring and being loyal to the
patient is more important, they may have to
deal with the hierarchical and bureaucratic
systems of institutions which demand loyalty
to subordinates to the institution. In case the
incompetent researcher is a higher status
professional, nurses may be obliged to show
loyalty, but this can conflict with loyalty to

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patients. Consequently, nurses may feel that
their patients are vulnerable and exposed
and that they can not prevent it because
they do not have a voice or power to resist.
This is merely why many authors believe that
it may not be possible for nurses to act as
advocates of subjects in research. Many
support the idea that the prohibition from
the advocacy role comes from the origins and
development of nursing as a women’s
occupation dominated by medicine in a
bureaucratic system.40
Another possible issue of conflict is that
the caring nature of nursing with regard to
the right of patients to the best
treatment/care is sometimes conflicting with
the aim of research in non therapeutic
studies. According to the Belmond
commission the general aim of practice is to
enhance the well being of individuals while
the purpose of research is to contribute to
general knowledge. This distinction
highlights the differences in the aims of a
nurse practitioner and a researcher. It is
therefore very difficult for nurses to be
engaged in studies whose aim is not directly
beneficial to the subject. They must though,
consider that these studies may generate and
refine nursing knowledge.
Another problem that nurses may have to
face is taking part in randomised control
trials. According to Brink and Wood
dedicated nurses are finding themselves
under pressure when they are asked to
exclude some patients from an obvious
beneficial treatment such as relaxation
techniques for relief of post operative pain.41
So, they suggest that whenever it is possible
to predict such problems for nurses, the
control data should be collected before
introducing the beneficial variable. Skodol
Wilson implies that there should be some
provisions for alternative effective care.42
Finally, Brink and Wood recommend that
withholding benefits can be rectified at the
end of an experiment.41 This compensation
must be planned in advance so that enough
money and time will be available.
In order to prevent human exploitation,
ethics committees were introduced.3 The
criteria on which the proposals are to be
judged are the physical and mental
discomfort or harm of subject, the
qualifications and experience of the
supervisor, the scientific value, the adequate
consent procedures and the adequate
information given to subjects.43 Clark warns
that there is a danger that the members may
have vested interests in a research.3 The
success of any ethics committee will always
depend on the commitment and moral
competency of its members. If instead of the
patient and his needs, the central aims of
the committee are personal interests, profits
and academic prestige, then nurses will have
none to share their concerns with, and deal
with their dilemmas in research.1 Nurses,
need a greater accessibility to committees
and demand a multidisciplinary synthesis in
order to deal with very difficult cases.26
Moreover, the committees should be less
strict so as not to prevent knowledge
development in nursing.
Confidentiality
The issue of confidentiality which is
stated as very important in the Hippocratic
oath, is another possible issue of conflict for
nurses either as practitioners or researchers.
Clause 10 of the ICN Code for nurses
emphasises that all information obtained
during nursing practice should be kept secret
apart from cases that it should be reported
in a court, or in cases that the interests of
society are important.9 On the other hand
the ICN Code for nurses in research states
that: "Nurses acting as data collectors must
recognise that they are now committed to
two separate roles " .26
According to the professional code they
can not reveal confidential information not
even to the members of the research team.
It is important therefore, to seek advice in
ethics committees to get approval for
disseminating the results of the data
collection including an account of what
happened.26 In addition, they have to deal
with the issue of anonymity when some
features of the research make the subjects
easy to identify.15 It is very important that
nurses always bear in mind that they should

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protect the privacy of the patient. The trust
showed to them must not be jeopardised.
Patients reveal information concerning their
body and mind and expect them to be used
only in a therapeutic manner. When
dilemmas according to confidentiality arise,
trust as a basic element of a therapeutic
relationship should be considered and
maintained.9
Informed consent
Nurses involved in research, have to
consider many ethical problems relating to
the issue of informed consent. The ICN code
for nurses in research, states that nurses as
practitioners may be called upon to witness
that informed and voluntary consent has
been obtained from the subjects of research.
It suggests that they should make sure that
patients have fully understood what has been
proposed, which means that they are aware
of potential risks or discomforts. Nurses who
spend more time with patients are in a good
position to judge it. In addition, they must
ascertain that patients have understood their
right to withdraw at any time. In order to
maintain the self-determination of patients,
nurses must be fully informed themselves
about the study and its purpose.44 The
patient's consent should be obtained freely,
with full awareness of implications. If nurses
find out that it was not obtained in an
appropriate manner, they should inform
patient and refuse co-operation. Webb
suggests that the informed consent is an
obligation of the researcher and no nurse
should obtain it on behalf of another
professional, nor agree to give the
explanation as a substitute.40 If a nurse tries
to get a consent, then the persons will feel
obliged to participate, either because
information is coming from their carer that
they trust and depend on, or, because they
feel grateful for the care they are
receiving.15
Another conflicting issue is that giving
information to patients is accepted as a
major role of the nurse; but if for the sake of
a research, nurses have to withhold
information, this may create conflicts when
they have to decide whether to participate
or not.40 Hurst suggests that if nurses cannot
tell patients about the true research
objectives, they should provide a full
explanation at the end of data collection.45
Provided, of course, that a supervisor body
has decided that disclosure should not be full
in order not to invalidate the research
outcome.
Consent, can however, be a major
ethical issue for nurses when it involves
persons with diminished autonomy, such as
children, aged, mentally ill etc. Nurses
should ascertain that consent has been
obtained either from the individual, when
possible, or, by relatives or guardians. They
must also protect the dignity and privacy of
such groups who are more vulnerable to loss
of dignity and privacy. Nurses taking part in
research on children should be alert, in order
to notice any verbal or non verbal dissent
which warrants exclusion of the child from
the study (even if this creates conflicts with
the researcher.46 In the same prospect,
nurses must act as advocates when
vulnerable groups are used in research, and
not prevent it. According to Levine,
restricting these groups from research could
end in disadvantaging those populations,
even further, especially when research
involves no risk and a high potential for
benefit.20
Researcher role conflict
With regard to nurse researchers, the
International Council of Nurses declares that
they are not responsible for the care of
patients. They should only intervene in case
that "a harmful situation appears imminent".
This statement is not congruent with the
culture of nursing which is "intertwined with
the ethic of caring".3 The commitment of
nurses to caring, may create dilemmas
according to the conflict between the
researcher's and clinician's role.
If a researcher nurse provides physical or
psychological care during an interview, the
results will be biased and generalisation will
be difficult.5

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12
Another issue raised from the ICN
statement, is to determine when a "harmful
situation appears imminent" and the
intervention of the researcher is required.26
The declaration of Helsinki says that the
interest of the individual should prevail over
the interests of society of science.3 This can
solve some of the ethical dilemmas of the
nurse, but in case the situation is not life-
threatening, the conflict remains. Burns and
Grove suggest that in case that support from
the researcher is required, then, it should be
given, but the subjects should be excluded
from the research.5 They also recommend
that another alternative, is to seek help in
other professionals to proceed with the data
collection. Nevertheless, most health
professionals, no matter how skilled they are
in supportive techniques will provide some
care if they feel that it is needed in a certain
case.
Conclusion
Ethical issues, conflicting values, and
ambiguity in decision making, are recurrently
emerging from literature review on nursing
research. Because of lack of clarity in ethical
standards, nurses must develop an awareness
of these issues and an effective framework
to deal with problems involving human
rights. This is necessary in order to come into
terms with the issue of the researcher's
values relative to the individual's rights
versus the interests of society. Professional
codes, laws, regulations, and ethics
committees can provide some guidance but
the final determinant of how research is
performed, rests with the researcher's value
system and moral code. To prepare future
nurses, ethics in research, must receive
special attention in nursing curricula. The
criticism and uncertainties that arise, should
be rather encouraged than suppressed in
nursing education. Hunt suggests that in
order to liberate nursing from its
"technocratic impasse" ethics should be
broadly interpreted as an arena of new ideas
which can change professional hierarchies, to
open cross-disciplinary discussions, and
question the concepts "abnormality",
"patient" and " illness". He also declares that
nursing, not as a biomedical branch, but as a
science and art of caring, is able to start the
redefinition of research in health care which
was in the recent history dominated by the
biomedical "paradigm".
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