A QUALITATIVE ANALYSIS OF ETHICAL PROBLEMS EXPERIENCED BY PHYSICIANS AND NURSES IN INTENSIVE CARE UNITS IN TURKEY

lu and Lale Alger Nesrin C obanog

Key words: ethical problems; intensive care; nurses; physicians In this qualitative study, we aimed to identify and compare the ethical problems perceived by physicians and nurses in intensive care units at Baskent University hospitals in Turkey. A total of 21 physicians and 22 nurses were asked to describe ethical problems that they frequently encounter in their practice. The data were analyzed using an interactive model. The core problem for both physicians and nurses was end-of-life decisions (first level). In this category, physicians were most frequently concerned with euthanasia while nurses were more concerned with do-not-resuscitate orders (second level). At the third level, we saw that almost all of the participants responses related to negative perceptions about euthanasia. Communication and hierarchical problems were the second most reported main category. Nurses were more likely to cite problems with hierarchy than physicians. At the third level, a large percentage of nurses described communication problems with authority and hierarchical problems with physicians. In the same category, physicians were most often concerned with communication problems with patients relatives. The ethical problems were reported at different frequencies by physicians and nurses. We asked the participants about ethical decision-making styles. The results show that nurses and physicians do not follow a systematic pattern of ethical decision making.

Introduction
Ethical issues have emerged in recent years as a major component of health care for critically ill patients.1 Advances in science and medical technology, recognition of ethics as a foundation for clinical practice, acknowledgement of new rights, an unlimited array of health care choices, and changes in social and family systems related to health care have strongly influenced the approach to critically ill patients during the last few decades.2,3 Intensive care units have developed to provide intensive monitoring and treatment with high technology equipment for critically ill
lu, Faculty of Medicine, Medical Ethics Address for correspondence: Nesrin C obanog Department, Baskent University, Eskisehir Yolu 20. km, Ankara, Turkey. E-mail: nesrin@baskent.edu.tr

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patients.4,5 Typically, intensive care units care for two types of patients: those who have an acute illness or a traumatic event, and those who have acute exacerbations of protracted, chronic illness.6 Despite the great advances in medical technologies, many patients spend their final hours in intensive care units. People throughout the world are afraid of dying a high-technology death with lingering, suffering, absence of control, and burdening of their family.7 Caring for critically ill patients in an intensive care unit means that difficult ethical problems must be faced and resolved.8 Two aspects of intensive care create ethical problems. First, intensive care is costly as a result of the high investment of human and technological resources, implying material costs as well as emotional strain on health providers due to patients suffering and dying. Secondly, in intensive care, life and death issues are often imminent.9 Intensive care units are traditionally focused on providing care for living persons, with often dramatic efforts to preserve life. Treatment of critically ill patients in todays intensive care unit is dictated by the latest developments in life-sustaining and life-saving technology.6,10 The greater control over life and death through advanced resuscitative techniques, life-support systems, monitoring equipment and computers not only transforms all previous limitations of mortality, but also appears to challenge basic ethical principles.11 Although advances in technology allow for better recovery and longer lives for critically ill patients, the same technological advances also give rise to moral and ethical questions.5,12,13 When can treatment be stopped or continued to a less than maximal degree? Who is to decide these issues, and by what standards? The resolution process in these new and open-ended questions requires critical analysis of ethical dilemmas according to the main principles of medical ethics. Among the many ethical problems facing physicians and nurses in intensive care units, some are encountered frequently: withholding or withdrawing life-sustaining treatment, overtreatment, do-not-resuscitate (DNR) status, artificial hydration and nutrition, distribution of limited resources, lack of respect for the patient as a person, and differences in perspective between physicians and nurses.2,8,9,12,14 16 Effective communication and collaboration among physicians and nurses are essential for high quality health care. Collaboration between nurses and physicians has been defined as physicians and nurses working together, sharing responsibility for solving problems, and making decisions to formulate and execute plans for patient care.17 The points of view of these two groups have to be identified to be able to create a perfect collaboration between physicians and nurses. In intensive care units where ethical problems are faced frequently, it is particularly important to determine and compare the perspectives of these two professional groups. We conducted focus group meetings to identify and compare the ethical problems perceived by physicians and nurses in intensive care units, which generated the following research questions: . What are intensive care unit physicians and nurses ethical problems? . What are the priorities of these ethical problems for physicians and nurses? . What methods are used to solve these ethical problems?

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Literature review
Several previous studies have examined the differences in ethical reasoning and decision-making frameworks between physicians and nurses. Walker et al. interviewed physicians and nurses about specific ethical problems encountered in the general medical services of a teaching hospital. They found that different ethical problems were identified when caring for the same patients: physicians perceived problems related to quality of life and the cost of care, while nurses were more concerned with patients and families wishes, implementing treatments, and pain management.18 Grundstein-Amado interviewed physicians and nurses working in acute and longterm care and found that nurses placed greatest emphasis on patient dignity, comfort and respect for the patients wishes, while physicians were most concerned with patients rights and quality of life. In the same study, the value of truthfulness dominated the nurses responses. In the physicians group, the dominant value was to n et al. interviewed physicians and nurses in medical and oncology avoid harm.19 Ude departments in northern Norway. They found that these two groups related different kinds of stories and seemed to use different ethical reasoning. Nurses stressed care and reasoned in accordance with relationship ethics, while physicians stressed justice and reasoned in accordance with action ethics.20 In a Swedish study, nurses and physicians in intensive care units narrated their being in ethically difficult care situations. Nurses were more frequently concerned with problems relating to relationships and choice of action, while physicians were most concerned with choice of action.8 Oberle and Hughes interviewed physicians and nurses in acute care adult medical-surgical areas, including intensive care. They found that the core problem for both physicians and nurses was witnessing suffering. The key difference between the groups was that physicians are responsible for making decisions and nurses must accept these decisions.14 Brett examined the most important ethical and psychosocial problems encountered by physicians and nurses in caring for critically and terminally ill patients: nurses were most likely to cite problems with communication and respect for patients, and physicians were more likely to highlight uncertainty and external factors, which included economic and legal issues.15 Haugen Bunch interviewed physicians and nurses in a neurosurgical intensive care unit and a trauma unit in Norway. The ethical dilemmas they faced were related to treating one versus treating many, end-oflife questions, and resource allocations with inadequate staffing.12 Ethical studies of end-of-life care in intensive care units often focus on debates about whether treatments are effective or futile, whether to withdraw or withhold lifesustaining therapy, and whether to administer cardiopulmonary resuscitation. Solomon et al. examined physicians and nurses views about life-sustaining treatments. Respondents expressed concern most often regarding the inappropriate use of mechanical ventilation and cardiopulmonary resuscitation, followed by dialysis and then artificial nutrition and hydration. Most respondents asserted that withdrawing a treatment is ethically different from deciding not to initiate the treatment at all.21 Manara et al. studied the primary reasons for withdrawing treatment in patients receiving intensive care. They found that these varied significantly depending on the patients age. In patients younger than 60 years old treatment was withdrawn more commonly for quality of life reasons and less for imminent death when compared with patients aged 60 years and over.22 Melia investigated ethical issues in intensive care

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and found that nurses were most concerned with the withdrawal and withholding of treatment.23 Conflict associated with decisions about withholding or withdrawing life-sustaining treatment may negatively affect patient care and the satisfaction of health care providers and family members. Breen et al., in their study about conflict associated with decisions in intensive care units, reported that disagreements over the actual life-sustaining treatment decision were the most common cause of conflict.24 Hinkka et al. showed that physicians end-of-life decisions vary widely according to personal background factors, such as age, gender and marital status.25 Finally, the aim of this study was to identify and compare the ethical problems perceived by physicians and nurses in intensive care units. The objective was to suggest techniques to prevent potential conflict in solving ethical problems between physicians and nurses in intensive care units.

Method
Design and sample
In order to learn more about the perceived ethical problems of physicians and nurses working in intensive care units at Baskent University hospitals, focus group meetings were conducted. Powell and Single defined a focus group as a group of individuals selected and assembled by researchers to discuss and comment on, from personal experience, the topic that is the subject of the research (p. 499).26 The main purpose of focus group research is to draw upon respondents attitudes, feelings, beliefs, experiences and reactions in a way that would not be feasible using other methods, for example observation, one-to-one interviewing, or questionnaire surveys.26 These attitudes, feelings and beliefs may be partially independent of a group or its social setting, but they are more likely to be revealed via the social gathering and interaction that being in a focus group entails. In addition, Powell and Single suggested that, as a qualitative data collection technique, the focus group has advantages over other qualitative methods, such as in-depth interviews and the nominal group technique.26 The ethical problems experienced by physicians and nurses in intensive care units are so deep and multidimensional that we thought that a focus group best suited this research. As there has been limited research on ethical problems in intensive care units in Turkey, we decided to conduct focus groups in order to capture the phenomenon as a whole. After completion of this research, a recommendation for a survey instrument that deals with ethical problems in intensive care units will be made. The study received approval from the Baskent University Research Committee and Ethics Committee. The focus groups included 21 physicians and 22 nurses (all experienced in intensive care procedures) from three different hospitals of Baskent University. Three cities were selected representing different regional areas in Turkey: the capital city, a metropolitan city, and a resort city. In addition, we selected hospitals where there were no limited resource problems because these may mask groups of other important ethical problems. From each hospital, groups of physicians and nurses were invited to a focus group meeting. To prevent hierarchical problems, we conducted two separate focus groups in each hospital: one for physicians only and one for nurses only. Participation was on a voluntary basis. The physicians and nurses

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who agreed to participate were asked for their informed consent. Two researchers conducted the proceedings, one as moderator and one being responsible for documentation. The researcher who was responsible for documentation noted the conversations during the focus group meetings. The sessions lasted for between 45 minutes and one hour. The participants were assured that the conversations in the focus group were confidential, would not be communicated to other parties, and would be reported as an aggregate. In addition, the participants were not identified personally. The numbers of physicians and nurses who participated in the focus groups are listed in Table 1. In total, 43 physicians and nurses participated. They varied in age and years of experience.

Data analysis
The data obtained from the qualitative part of the instrument were analyzed using an interactive model.27 For the resort and metropolitan city hospitals, data were collected by tape-recording and then transcribed. In the capital city hospital, tape-recording was not allowed by some of the participants, so notes were taken during the discussions. The data were transcribed and listed, and then divided into three categories, as the interactive model suggests for the data reduction stage. These three categories were created by the depth of the information given. At the first level, data were categorized according to three general areas (end-of-life decisions, communication and hierarchical problems, and social problems). The three first-level categories were then fed into the second level, which was more detailed (e.g. euthanasia, futile treatment, DNR decisions and autonomy emerged in the end-of-life decisions category at the second level). Finally, a third level was created to show detailed information about the second level categories (e.g. autonomy of child patients and autonomy of young patients emerged under the autonomy category at the third level). A chi-squared analysis was conducted for both physicians and nurses for each level. All analyses were performed using the SPSS program.

Findings and discussion

Table 2 shows the first level of categorization. Each response to a question asked was coded using a spreadsheet program, and then placed into one of three categories: end-of-life decisions, communication and Table 1 Participant details
No. physicians Male Capital city Metropolitan city Resort city Total 2 3 3 8 Female 6 4 3 13 No. nurses Male 0 0 0 0 Female 7 7 8 22 15 14 14 43 Total

Hospital location

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Category End-of-life decisions Communication and hierarchical problems Social problems Total * Significant at 0.001 level.

449

Main categories of responses (level 1)

No. physicians (%) 120 (48.4) 71 (28.6) 57 (23.0) 248 (100.0) No. nurses (%) 55 (46.2) 51 (42.9) 13 (10.9) 119 (100.0) Chi-squared 45.06* 509.37* 302.18* df 2 18 19

hierarchical problems, and social problems. The issue most cited by physicians and nurses was end-of-life decisions, which were mentioned by almost the same percentage of physicians (48.4%) and nurses (46.2%). End-of-life decisions are decisions on the treatment of patients that result in either delay or hastening of dying. They play an important role in the intensive care unit.4,28 In this study, the end-of-life decisions category included ethical problems such as euthanasia, withdrawing and withholding treatment, and DNR decisions. The second most common category, communication and hierarchical problems, was reported by nearly 30% of physicians and by 43% of nurses. This included problems with communication among physicians, nurses, patients and patients relatives, and problems concerning the hierarchical structure. Nurses were more likely to cite communication and hierarchical problems than physicians, which may result from nurses more sustained contact with patients and their families. In a study concerning perspectives of physicians and nurses in caring for critically and terminally ill patients, Brett found that communication was more problematic for nurses than for physicians.15 Finally, 23% of physicians and 10.9% of nurses reported issues around social problems. This category included obstacles to solving ethical problems in intensive care units, such as economic barriers and the beliefs of physicians. For each main category, a chi-squared analysis was conducted to detect significant differences in frequencies between physicians and nurses. The results given in Table 2 show that, at each level, the differences between physicians and nurses were significant. Although the priority list did not change, the weight given to each category differed between the professional groups. In the second and third levels of data analysis, each of the categories that emerged in level 1 analysis was categorized for one further level. The responses for level 2 are reported in Table 3. The following ethical problems emerged under the end-of-life decisions main category: euthanasia, treatment refusal, futile treatment, brain death, DNR decisions, objectification, organ donation, and autonomy. The physicians were most frequently concerned with euthanasia and nurses were more often concerned with DNR status. In this study, passive euthanasia included the withholding and withdrawing of lifesustaining treatments. Overtreatment is a major ethical dilemma in modern medicine, but the withholding and withdrawing of treatments are processes by which various medical interventions are either not given to patients or are discontinued with the expectation that they will die of their underlying illness.29,30 Prolonging the process of

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lu and L Alger NC obanog Ethical problems reported by physicians and nurses (level 2)
Level 2 Euthanasia Treatment refusal Futile treatment Brain death DNR decision Objectification Organ donation Autonomy Total Communication problems Hierarchical problems Paternalism Total Economic barrier Inadequate staffing Priority of patients Social situation of patients Beliefs of physicians Limited resourcesa Nursing home Care at home Total No. physicians (%) 54 0 19 10 21 0 2 14 (45.0) (0.0) (15.8) (8.3) (17.5) (0.0) (1.7) (11.7) No. nurses (%) 10 1 0 1 20 16 0 7 (18.2) (1.8) (0.0) (1.8) (36.4) (29.0) (0.0) (12.8)

Table 3
Level 1

End-of-life decisions

120 (100.0) 49 (69.0) 19 (26.8) 3 (4.2) 71 (100.0) 18 2 0 0 6 27 1 1 (32.8) (3.7) (0.0) (0.0) (10.9) (49.0) (1.8) (1.8)

55 (100.0) 35 (68.6) 16 (31.4) 0 (0.0) 51 (100.0) 2 1 2 2 0 4 0 0 (18.2) (9.0) (18.2) (18.2) (0.0) (36.4) (0.0) (0.0)

Communication and hierarchical problems

Social problems

55 (100.0)

11 (100.0)

It is important to note that limited resources emerged as positive in these sample hospitals, meaning that they did not have financial resource problems as in other hospitals; in Turkey, resources in intensive care units remain problematic and may create additional ethical dilemmas or social conflict among the intensive care unit staff.

dying is not in a patients best interests as it goes against the ethical principles of beneficence and nonmaleficence.31 From an ethical point of view, any treatment that does not provide benefit to a patient may be withheld or withdrawn.2,25,30,32 In Turkey, after brain death is declared to a patients relatives, and waiting for at least 12 hours for patients whose diagnosis is known and at least 24 hours for those whose diagnosis is not known, medical support can be terminated with relatives consent.33 Most of the physicians and some of the nurses described conflict about withholding and withdrawing life-sustaining treatment. Many participants reported that deciding to withdraw treatment once initiated is ethically more difficult than not initiating it. In the literature, similar findings support these results.11,25,31,34 One young physician reported the problem of withdrawal of treatment as: The most difficult one is to let the patients go. I am never sorry for this but this touches my nerves. This young and successful, but inexperienced, physician is affected deeply by end-of-life decisions and, in order to cope with these difficult situations, he has developed psychological defence systems. However, he is still not successful in this endeavor; he is affected emotionally and becomes angry towards himself. For this reason, he expresses that he is not affected; the contrary is the case: he is very much affected.

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DNR status means that, if cardiopulmonary arrest occurs, no resuscitative measures are to be initiated.35 Despite the extensive literature devoted to DNR orders, they continue to raise vexing problems for physicians, nurses and policy makers. The difficulties include physicians ambivalence about who should be consulted before a DNR order is written, the frustration of nurses who are asked to continue complicated or invasive treatments of a patient for whom a DNR order has been written, and hospital administrators uncertainty and confusion over what their DNR policies should be.36 In this study, the nurses most often placed DNR decisions in the end-oflife decisions category. We think there are two reasons for this result. First, there may be uncertainty in the absence of written DNR orders, and, secondly, physicians are responsible for DNR decisions, but nurses have to accept these decisions. Each of the ethical problems reported at different frequencies by physicians and nurses may indicate their priority list. For example, there were wide differences in responses across the two professional groups for the end-of-life decisions main category. The reason why the priority list of ethical problems differs between the two groups may be that physicians are more involved in managing scientific information related to disease while nurses focus on patients care and comfort. For example, although DNR decisions appeared in the priority list of ethical problems for both groups, physicians are involved in making DNR decisions while nurses are involved in applying these DNR decisions. Under the communication and hierarchical problems main category, communication problems, hierarchical problems and paternalism emerged as ethical delemmas. In the second level, almost the same percentage of physicians (69.0%) and nurses (68.6%) reported issues around communication problems. Nurses were, however, more likely to cite hierarchical problems than physicians. Similar findings related to hierarchical problems support these results in work done by Oberle and Hughes,14 van der Arend and Remmers van-den Hurk,37 and Asai et al.38 Other findings cannot support that this is the case in other hospitals in Turkey, but they can show that opinions in Turkey are similar elsewhere. Finally, in the social problems main category, the following ethical problems were reported: economic barrier, inadequate staffing, priority of patients, social situation of patients, beliefs of physicians, limited resources, nursing home care, and care at home. The physicians were more likely to cite the economic barriers than nurses. Similar findings related to economic factors support these results in work done by Brett.15 In contrast, nurses were more concerned with patients priorities and their social situation. We then proceeded to level 3 to try to understand the reported ethical problems in more detail. Table 4 shows the ethical problems at the most detailed level. At the second level, for example, 45% of the physicians and 18% of nurses reported euthanasia as an ethical problem. However, at the third level, we see that almost all of these responses related to negative perceptions about euthanasia. In that particular example, of the ones who reported, about 2% of physicians and 10% of nurses favored euthanasia while 82.7% of physicians and 50% of nurses opposed it. Similarly, 13.5% of physicians and 40% of nurses were opposed to euthanasia for a child patient. One physician said:
I cant accept euthanasia. The patient in that situation has no ability to decide. His or her relatives make the decision. We are obliged to make the patients live. I favor giving a chance to the patients until the end. As a physician I dont want to be remembered as the one pulling the mechanical ventilators plug.

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lu and L Alger NC obanog Ethical problems reported by physicians and nurses (level 3)
Level 2 Euthanasia Level 3 Euthanasia yes Euthanasia no Euthanasia for a child patient no Patients relatives desire euthanasia Total Futile treatment Futile treatment Futile treatment for elderly patients Total Autonomy Autonomy Autonomy for child patients Autonomy for young patients Total No. No. physicians (%) nurses (%) 1 (1.9) 43 (82.7) 7 (13.5) 1 (1.9) 52 (100.0) 13 (68.4) 6 (31.6) 19 (100.0) 2 (14.3) 8 (57.1) 4 (28.6) 14 (100.0) 27 (56.2) 21 (43.8) 0 (0.0) 48 (100.0)) 8 (42.1) 0 (0.0) 0 (0.0) 8 (42.1) 1 (5.3) 2 (10.5) 0 (0.0) 19 (100.0) 1 (10.0) 5 (50.0) 4 (40.0) 0 (0.0) 10 (100.0) 0 (0.0) 0 (0.0) 0 (0.0) 1 (14.3) 4 (57.1) 2 (28.6) 7 (100.0) 13 (37.1) 8 (22.9) 14 (40.0) 35 (100.0) 0 (0.0) 12 (85.7) 1 (7.1) 0 (0.0) 0 (0.0) 0 (0.0) 1 (7.1) 14 (100.0)

Table 4
Level 1

End-of-life decisions

Communication Communication Communication problems with patients and hierarchical problems relatives problems Communication problems with patients Communication problems with authority Total Hierarchical problems Hierarchical problems among physicians Hierarchical problems with physicians Hierarchical problems among nurses Hierarchical problems with nurses No hierarchical problems with physicians No hierarchical problems with nurses Problems with management Total

When medical treatment is believed to be ineffective in treating illness or improving quality of life, it is described as futile.3,39 The questions surrounding medical futility always concern physician paternalism and patient autonomy.3 Health care providers in intensive care units can often experience medical futility situations. In this study, 68.4% of the physicians reported futile treatment as an ethical problem. Treatments

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that merely prolong dying and cause suffering were a source of great distress for these physicians, one of whom said:
The patients who have least possibility of getting well pose the biggest problem. These patients breathe, defecate, and their hearts beat. And we try to make them live. I think one has the right to die.

It can be seen that these physicians and nurses face more problems of autonomy in child patients compared with adult patients. The reason for this may be that parents are required by law to make decisions regarding their children, which may conflict with physicians and nurses perception of benefit to patients. For example, while physicians and nurses propose to continue treatment in child patients, parents may want to terminate life support or treatment. This may create an environment for physicians and nurses in which they experience conflict due to more responsibility towards child patients in applying the parents decisions. One physician said:
I feel uncomfortable when the patients relatives want euthanasia. I am a pediatrician. I feel uncomfortable when patients have diseases that cause disabilities and end-stage cirrhosis. If I dont do anything I feel uncomfortable emotionally. At first they have hope but later they lose that.

In the communication problems category, the issues most cited by physicians were problems with patients and patients relatives (level 3). The higher frequency for the physicians compared with the nurses may indicate that physicians are more concerned with scientific processes than with patients relatives. However communication with patients and their families is an important part of nurses role and they may have more contact with patients and families than other health care professionals in intensive care units.40 Patients and families may feel more comfortable when discussing their concerns with nurses rather than with physicians. In the same category, the most reported issue by the nurses was communication problems with authority. In the hierarchical problems category, a high percentage of nurses also described hierarchical problems with physicians. Nurses not only have relationships with the patients and their families, but they work closely with physicians and have responsibilities delegated by their employing organization. The hierarchies of different professional groups affect how members can act out their own moral position. In the literature, the generally lower position of nurses in hierarchical structures is referred to as an important cause of moral problems and burnout.14,15,37 In this study, hierarchical problems between physicians and nurses were related to nurses lower position on the hierarchical structure. For example, being unable to influence decisions, being expected to remain silent despite their professional knowledge, and their detailed understanding of patients condition made these nurses feel uncomfortable. This finding is in line with Chambliss research on the impact on nurses of implementing decisions but having little or no voice in the decision-making process.41 One nurse said, I am the person who observes and knows the patient most. I think I have the right to give information but I think this is hindered by a physician. Sometimes a person who is lower in the hierarchical structure has to carry out orders from a superior that are against his or her own conviction.42 Another nurse said:

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In my old hospital, there was a patient with diabetic ketosis in the clinic, aged 35 /40. One of our patients brought a cake. The physician opened the cake box and the patient wanted a piece. The physician refused. I gave one piece to my patient and, after she left, I fixed her insulin dose. I said nothing to anybody. However I slept well that night.

We believe that these results show the status of nursing in Turkey, where there is a rigid hierarchy between physicians and nurses. Nursing is often considered as subordinate to medicine. In addition, most physicians are male and all of the nurses are female.43 In accordance with traditional sex roles, physicians are encouraged to be decisive and to act with authority. Studies indicate that physicians view themselves as omnipotent.35 Nurses are often expected to follow decisions or recommendations given by physicians.

What are the solutions to these ethical problems?

The ethical decision-making process is the core element that embodies health care practice, yet its nature and complexity have changed dramatically owing to major advances in technology and scientific progress, and to economic constraints. These trends and developments have placed a heavier burden and more demands on health care providers to cope effectively with emerging ethical problems.44 In this study, the nurses and physicians did not follow a systematic pattern of ethical decision making. When asked how they would solve the ethical problems, nurses responded that they would ask the physicians, and physicians reported that they would ask colleagues one level up the professional hierachy. In only one hospital did physicians and nurses make decisions together. Decisions were made in a narrow, habitual manner, through the elimination of the most significant and demanding elements of the decisionmaking process, such as problem perception, information processing, gathering medical information, listing the alternatives and the possible consequences. Grundstein-Amado investigated the ethical decision-making processes used by health care providers and found that they did not follow a consistent and systematic pattern.44

Conclusions
In intensive care units, where ethical problems are faced frequently, it is particularly important to determine and compare the different perspectives of physicians and nurses, which was the purpose of this qualitative study. The core problem for both the physicians and the nurses was end-of-life decisions. Communication and hierarchical problems constituted the second most reported main category. The findings of this research have shed light on the dimensions and attributes of ethical dilemmas in intensive care units as experienced by physicians and nurses. At the same time, we have observed that the same dilemma can be perceived differently by physicians and nurses. Observed differences between physicians and nurses were related to the hospitals hierarchical structure and the traditional distinctions between nurses and physicians roles. Nurses tended mostly towards the ethics of care, which considers emotional commitment and willingness to act on behalf of persons with whom one has a significant relationship.45 Besides their scientific knowledge, in this environment the

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nurses favored a humanistic approach in their relationships because they are the witnessess of the special situations of patients and their individual differences. Compared with the nurses, these physicians working in intensive care were less aware of patients individual differences. In their choices and solutions to ethical problems, the scientific approach and the principle of beneficence remained superior. It is important that both these professions should make ethical decisions together and put them into practice together. Futile treatment is a serious problem for physicians, yet the nurses did not comment on this. For the nurses, physical restraint of patients is a serious problem, but the physicians did not mention them. The nature of the physicians and nurses professional roles showed that they identified more ethical problems in the areas for which they are responsible. The concept of responsibility is important in ethical problems. Both professional groups felt more sensitive to and responsible for pediatric patients. They were more interested in the prognosis and more affected by positive or negative results in children. Both groups stressed that there should be no euthanasia for pediatric patients and, when problems of autonomy were considered, this was a sensitive subject. Although it is the responsibility of management to control effectively the application of standard treatment and care protocols in intensive care units, they also have an important duty to explain the reasons behind the protocols. We should be cautions about applying administrative solutions to problems of the hierarchical structure that are experienced by both professional groups, but felt more acutely by nurses. Hierarchical problems between physicians and nurses are expressed here as everywhere else in the world. In Turkey, nurses graduate at different levels from nursing school. Although the nursing schools who provide two years of undergraduate education based on high schools and nursing schools based on primary schools are to close, nurses who have attended these courses are still in practice. We hope that the hierarchical problems caused by the different educational levels will soon be solved by the increase in the number of nurses educated in schools providing graduate education and those who have undergone postgraduate education. A suggestion that would affect the quality of education in both professions is professional values formation and teaching value systems that foster ethical and effective co-operation with other professions involved in health care. Additionally, in medical and nursing schools, the ethics curriculum could be shaped towards nurses and physicians becoming more sensitive to ethical problems faced especially by patients towards the end of their lives. It is important for both professions to express their reasons for the positive or negative ways in which decisions are made concerning practice in these areas. We think that the solution to most of the problems analyzed in this study is effective cooperation and communication between physicians and nurses at every level of patients treatment and care. The ethical way of coping with the difficult decisions having to be made by physicians and nurses is by talking and acting together, which would constitute good practice.

Limitations
This study has several limitations. First, the findings cannot be generalized beyond the population surveyed. Secondly, although focus group research has many advantages,

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as with all research methods, there are limitations. Some of these may be overcome by careful planning and moderating, but others are unavoidable and peculiar to this approach. The researcher, or moderator, for example, has less control over the data produced than in either quantitative studies or in one-to-one interviewing.46 The moderator has to allow participants to talk to each other, ask questions and express doubts and opinions, while having very little control over the interaction other than generally keeping participants focused on the topic. By its nature, focus group research is open ended and cannot be entirely predetermined. It should not be assumed that individuals in a focus group are expressing their own definitive individual view. They are speaking in a specific context, within a specific culture, and sometimes it may be difficult for the researcher to identify clearly an individual message. This too is a potential limitation of focus study groups.26

Future directions
This research turned out to be very fruitful. We were delighted with the depth and richness of the information gained from the focus groups. One solid outcome is the development of a self-administered survey in which these ethical problems and their solutions will be covered. This survey will be administered to a much larger physician and nurse population in order to be able to generalize the findings to a larger group. Future research needs to focus on the ethical problems and decision-making styles of physicians and nurses from different clinical areas.

Acknowledgements
The authors would like to thank the physicians and nurses who participated in the lu who assisted with the studys methods and focus groups, and to Dr Cihan C obanog statistics. lu and Lale Alger, Baskent University, Ankara, Turkey. Nesrin C obanog

References
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Editors note
Previous articles related to this theme are: Haugen Bunch E. Hidden and emerging drama in a Norwegian critical care unit: ethical dilemmas in the context of ambiguity. Nurs Ethics 2001; 8: 57 /68. Leino-Kilpi H, Suominen T, Ma kela M, McDaniel C, Puukka P. Organizational ethics in Finnish intensive care units: staff perceptions. Nurs Ethics 2002; 9: 126 /36.

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