Do you think it is possible to protect this vulnerable population during a research study? How do the authors apply the four ethical principles when dealing with a vulnerable population such as incarcerated pregnant women?
Received: 23 June 2022
Revised: 24 July 2022
Accepted: 11 August 2022
DOI: 10.1111/jonm.13764
COMMENTARY
Promoting nurses’ and midwives’ ethical responsibilities
towards vulnerable people: An alignment of research and
clinical practice
Adele Baldwin PhD, MNSt, RN, RM, Associate Professor1
|
Tanya Capper PhD, MMid, GradDipMid, L.LB, DipHEMid, RM, Head of Course,
Midwifery2
| Clare Harvey PhD, RN, BA, MA, Professor3
|
Eileen Willis PhD, MEd, BEd, Emeritus Professor4
|
Bridget Ferguson BNurs, MMid, GradCertMid, RN/RM, Lecturer5
Natalie Browning BA, MEd, BN/Mid, RN, RM, Associate Lecturer1
1
School of Nursing, Midwifery and Social
Sciences, CQUniversity, Townsville,
Queensland, Australia
|
Abstract
Aim: To stimulate discussion and debate about the inclusion of vulnerable popula-
2
School of Nursing, Midwifery and Social
Sciences, CQUniversity, Brisbane, Queensland,
Australia
3
School of Nursing, Massey University,
Wellington, New Zealand
4
Flinders University, Adelaide, South Australia,
Australia
5
School of Nursing, Midwifery and Social
Sciences, CQUniversity, Rockhampton,
Queensland, Australia
tions in primary research to inform practice change and improve health outcomes.
Background: Current research practices to safeguard vulnerable people from potential harms related to power imbalances may in fact limit the generation of evidencebased practice.
Evaluation: The authors draw on their experience working and researching with a
recognized group of vulnerable people, incarcerated pregnant women, to provide
insight into the application of ethics in both research and clinical practice. In a novel
approach, the ethical principles are presented in both contexts, articulating the syner-
Correspondence
Tanya Capper, School of Nursing, Midwifery
and Social Sciences, CQUniversity, Brisbane,
Qld 4000, Australia.
Email: [email protected]
gies between them. Suggestions are presented for how individuals, managers and
organizations may improve research opportunities for clinical practitioners and
enhance the engagement of vulnerable people to contribute to meaningful practice
and policy change.
Key Issues: Ethical practice guidelines may limit the ability to create meaningful
change for vulnerable populations, who need authentic system change to achieve
good health outcomes.
Conclusion: Inclusive research and practice are essential to ensuring a strengthsbased approach to healthcare and addressing health needs of the whole population.
Health systems and models of care recognizing the diverse lives and health needs of
the broader population demand practical, sustainable support from clinical managers.
Implications for Nursing Management: Practical suggestions for clinical managers to
support point of care research is provided, embedding vulnerable voices in policy,
practice development and care provision.
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made.
© 2022 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd.
2442
wileyonlinelibrary.com/journal/jonm
J Nurs Manag. 2022;30:2442–2447.
2443
COMMENTARY
KEYWORDS
case study, ethical nursing practice, research ethics, vulnerable populations
1
|
I N T RO DU CT I O N
research informing clinical practice is mentioned, albeit briefly, in both
aforementioned codes of ethics. Howe
Nursing and midwifery practice is framed by professional codes of
ever, despite this, the role of nursing and midwifery researchers is
conduct, ethics and standards of practice. These frameworks seek to
often overlooked. Whilst there is a strong focus on the ethics of pro-
ensure the provision of care meets the expectations of the commu-
viding quality clinical care, less consideration is given to nurses and
nity, the professions and individuals, contributing to the best possible
midwives involved in research. Hayes (2006) clearly links the Code of
health outcomes for the recipient. The International Council of Nurses
Ethics requirement that nurses should treat all people as equals, con-
(ICN) and the International Confederation of Midwives (ICM) provide
sidering individual circumstances to promote inclusivity and addres-
the overarching ethical frameworks within which all nurses and mid-
sing ‘hidden coercive influences’ (p. 87). It is therefore imperative that
wives must practise. Specifically, the ICN Code of Ethics for Nurses
nurse and midwife researchers contribute to the building of a body of
(ICN, 2021) identifies four principal elements for ethical conduct:
knowledge in order to best advocate for all recipients of care.
nurses and patients or other people requiring care or services; nurses
The authors draw on their experiences of evaluating a project
and practice; nurses and the profession; and nurses and global health
that included working alongside and conducting research with a vul-
(p. 3). The ICM (2014) International Code of Ethics for Midwives bases
nerable
population
of
pregnant
women
in
prison
(Baldwin
its core ethical code on the recognition of women’s human rights and
et al., 2018). Pregnant women in prison are considered vulnerable by
the role of the midwife in supporting and advocating for women.
their gender, incarceration, pregnancy, culture and socio-economic
Point 1c of the code states ‘Midwives empower women/families to
background (Baldwin, Sobolewska, et al., 2020). The juxtaposition of
speak for themselves on issues affecting the health of women and
clinical practice and the importance of engaging vulnerable popula-
families within their culture/society’ (ICM, 2014 p.1).
tions in primary research to hear the voices of those who may be
The concept of advocacy is foregrounded throughout both pro-
silenced by complex social, cultural and political influences is explored.
fessional frameworks, explicitly as per Element 1.7 of the ICN Code of
The authors’ new insights demonstrate how practice and research
Ethics (ICN, 2021, p.7) or in a more nuanced manner throughout the
with vulnerable people are aligned, enhancing outcomes for theoreti-
International Code of Ethics for Midwives (ICM, 2014). Accordingly, it
cal understanding and practical application. The need for primary
is expected that nurses and midwives build trusting relationships with
research, centred around the most vulnerable is highlighted, and sug-
the recipients of care, support them in their healthcare decision mak-
gestions will be made for future research involving vulnerable people,
ing and advocate for change to provide the best possible health
without compromising the research process or compounding the par-
outcomes.
ticipants vulnerabilities.
People from disadvantaged or vulnerable backgrounds are overrepresented in poor health statistics (Ford et al., 2021) and are often
the most frequent seekers of care (Cruwys et al., 2018). For many,
2
|
BAC KGROU ND
engaging with health care providers is fraught with challenges, including, but not limited to, access to care, understanding of need and
Ethical practice in research is not a new concept. In the aftermath of
adaptability of services (Byrne et al., 2022; Lewis et al., 2012). For
WWII, the urgent need to protect the vulnerable resulted in the
many, non-engagement with healthcare providers is reflective of an
Nuremberg Code, followed in 1964 by the Helsinki Declaration
overall disengagement with institutions more broadly and demon-
(Mandal et al., 2011). It is beyond doubt that the events leading up to
strates a level of structural vulnerability for the individual. Structural
the development of these cornerstone documents dictated the need
vulnerability is a term that describes the complex social determinants
for regulation to prevent further research activity that could result in
that contribute to factors that result in poor health outcomes
harm, maim or even kill innocent participants. Since then, formal
(Bourgois et al., 2017). Further Bourgois et al describes structural vul-
ethics committees have become embedded into organizations that
nerability as ‘the outcome of a combination of socioeconomic and
engage in research (Brown et al., 2020). Alongside the growth of
demographic attitudes, in conjunction with assumed or attributed sta-
ethics committees, the definition of vulnerability has evolved to rec-
tus’ (p. 4). Therefore, the vital role that nurses and midwives play in
ognize the many layers of vulnerability more accurately across
confronting these factors and in facilitating patient engagement can-
communities.
not be overstated.
Over time, restrictions on vulnerable people participating in
Contemporary healthcare practice is based on evidence-based
research due to concerns about causing them harm have increasingly
knowledge (Boswell & Cannon, 2022). However, in order to build an
been called into question, raising issues about the exclusion of vulner-
appropriate evidence base, rigorous and credible research that meets
able groups from being represented in research (Hayes, 2006). For
a strict ethical criterion is essential. The fundamental importance of
example, non-participation or exclusion from participating in research
2444
COMMENTARY
may in fact be placing vulnerable populations at a further increased
group contributes to the lack of evidence-based understanding of
risk of harm (Juritzen et al., 2011). Using healthcare provision in prison
their situation, from analysis of primary data rather than the more
as an example of vulnerability in context, the lack of primary research
commonly used data sources of document review or research with
with offenders is apparent. There is an overall dearth of research
people who are not the primary concern. We support the view that it
about health in prisons, with most of the evidence being drawn from
is unethical not to undertake research with vulnerable populations
statistical data provided by health services or research around medical
(Alexander, 2010; Krubiner & Faden, 2017) as the need to elicit mean-
chart audits and reviews. This absence of the person and their lived
ingful findings is paramount to those concerned. In fact, the exclusion
experience of healthcare delivery within prison indicates a significant
of this group may, cause harm as it represses their voices, further con-
gap in knowledge, particularly when considered from the perspective
tributing to their isolation (Aldridge, 2015). Vulnerability is not static,
of person-centred care.
its levels fluctuate in response to the environment and other physical
The complexities of vulnerability are well illustrated in the cases
of incarcerated pregnant women, with the recent development of for-
and emotional factors that are at play at any specific time
(Biros, 2018).
mal recommendations to improve health and well-being outcomes for
Usually, there is a distinction made between research ethics and
this group of mothers and babies (Baldwin, Capper, et al., 2020; Birth
clinical practice ethics. However, our experiences demonstrate the
Companions, 2016). The number of incarcerated women around the
necessary links that nurses and midwives must make between
world is increasing, many of which are of childbearing age, (Alirezaei &
research and practice in order to operationalize best evidence, con-
Roudsari, 2022; Gibson, 2022), are from poor socio-economic back-
tribute to new knowledge, provide high-quality care and align with
grounds and have higher levels of emotional and mental health trauma
ethical clinical practice. Our novel approach to this complex situation
than the general population (World Health Organization, 2014). Often
is illustrated in the following table. Table 1 shows how our methodo-
women moving through the criminal justice system lead chaotic lives,
logical approach addressed all four basic ethical principles for research
involving complex social issues, resulting in prison sentences related
and how those concepts may be operationalized in the clinical
to illicit drugs, violence and robbery (Breuer et al., 2021).
environment.
Pregnant women are regarded as a vulnerable population due to
The application of the ethical principles in both contexts is a novel
a perceived lack of capacity to give informed consent for an unborn
illustration of how ethics underpins all aspects of nursing and mid-
child and thereby are seen to pose a greater potential for harm.
wifery. Further, it demonstrates the inextricable links beyond that of
Because of this classification of vulnerability, there has been a reluc-
evidence informing practice. It shows that the ethical conduct of
tance to undertake research involving them. Despite this hesitancy, it
research could be considered a natural extension of ethical nursing
has been suggested that the exclusion of vulnerable populations may,
and midwifery practice. There is scope for nursing and midwifery
in fact, cause them more harm as it further suppresses their voices,
managers to support the conduct of research, involve clinical staff in
thereby contributing further to their marginalization (Aldridge, 2015).
research and extend the concept of woman-centred care by placing
Incarcerated women have been described as ‘the most vulnerable
vulnerable women at the centre of new understandings as well as at
population of women’ (Hayes, 2006, p. 84). Therefore, incarcerated
the centre of their care.
pregnant women may be categorized as an even more vulnerable
population.
Contemporary strategies implemented by all levels of government
around the world centre on the concept of inclusivity. It is our asser-
The paradox of this situation is that pregnancy alone should not
tion that these strategies promote inclusion on multiple levels: one, to
be considered the causation of increased vulnerability as it is consid-
actively engage clinicians in research and two, to design research to
ered a state of well-being rather than illness. Therefore, it could be
uphold the ethical principles allowing for both protection and partici-
argued that it is in fact unethical not to undertake research with vul-
pation with vulnerable groups. Our insights demonstrate a need for
nerable populations, such as pregnant incarcerated women as the
these same organizations to extend inclusion strategies to ensure that
need to elicit meaningful findings is paramount with enormous poten-
all voices are heard. It seems reasonable that, whilst upholding the
tial benefits (Alexander, 2010; Krubiner & Faden, 2017). Further, cur-
ethical principles, nurses and midwives are well positioned to seek out
rent evidence suggests that the prison environment may contribute to
and embed ways of engaging the disenfranchised and marginalized in
improved birthing outcomes and being pregnant whilst ‘inside’ pro-
research studies. Engagement and inclusion may increase self-worth
vides the incentive for a woman to transform her life with positive
and perception of self within the broader community and thereby
birthing and effective parenting experiences offering an opportunity
increase power status for those who have the least. As outlined in
to interrupt the cycle of recidivism (Shaw et al., 2015).
Table 1, building relationships is fundamental to creating a research
culture in practice, and these relationships should be across disciplines, contexts, organizations and regions, drawing on the formal and
3
|
DISCUSSION
informal networks that nurses and midwives are part of. Adopting a
research-engaged culture and providing support for clinicians to be
Our experience foregrounds the often-avoided topic of doing ethical
actively involved in research are essential elements to increasing
research with vulnerable people (Gordon, 2020). Recognition of a
nurses’ and midwives’ ownership of the evidence for their practice.
population such as incarcerated pregnant women as a vulnerable
Redesigning old strategies such as journal clubs is one way in which
2445
COMMENTARY
TABLE 1
Ethical principles in nursing and midwifery research and practice
Ethical principle
Ethical research design
Ethical clinical practice
Autonomy—Seeks to uphold the
individual’s right to selfdetermination without bias or
influence
Relationships built between researcher and
participant
Researchers are not employed by the government or
by corrective services
Information sheets and consent forms will be
worded to an agreed literacy level
All consenting participants will be invited to
participate in all aspects of the study
The ethical principles for nurse and midwives are
visible and embedded into organizational policy
and clinical practice expectations
Considerations and respect for different ways of
knowing and understanding are foregrounded in
organizational and clinical practice
All recipients of care are given the option to make
informed decisions and if they choose, decline or
redefine their care
All clinical decision making places the recipient of care
at the centre and prioritizes their individual
choices, empowering them to be active
participants, rather than passive recipients
Professional relationships between the clinician and
the recipient of care are established and nurtured,
supported by nurse and midwife managers and
organizational governance processes
Justice—Research outcomes must
be fairly and equally distributed
Findings will not be disseminated without full
consent from the participants
Transcripts of are the collective property of the
participants and research team
Full and accurate explanations of care management
options are given, clarified and confirmed with all
recipients of care
Equity in access to appropriate services is enhanced
by individual and organizational practice
Clinicians ensure that current evidence is embedded
in practice to ensure consistent, quality care
across settings for all recipients of care
Nurse and midwife managers, in consultation with all
staff, ensure that adequate resources are available
to meet the standard-of-care expectations
Non-maleficence—No harm comes
to those who participate in the
research or in the broader
community
Fact checking with the participants conducted prior
to final publication and dissemination of findings
All precautions will be taken to protect
confidentiality, privacy and identity of
participants with ongoing review during the
research process
Data collection methods promote the creation of
safe spaces
Researchers will adopt a reflexive stance
When providing education, clinicians clarify
understandings with the recipient of care,
redirecting or explaining where required
All recipients of care are offered the opportunity to
participate in research and policy development
where appropriate. Similarly, all recipients of care
can decline or withdraw participation without
impact on their care
All nurses and midwives, across all levels of practice,
including nurse and midwife managers, engage in
reflection and reflexivity as part of their
continuing professional development
Beneficence—Research must be
conducted with the intent to do
good
The research team are already known to the
potential participants and have built relationships
over a period of time
All researchers will demonstrate reflexivity in their
research practices and keep a journal during the
study
Opportunities will be provided for participants and
researchers (separately) to debrief
Findings will be disseminated to the academic
community, funding/supporting agencies, and
the participants with opportunities to discuss and
debrief
All healthcare professionals involved in the provision
of care establish respectful relationships with
recipients of care
Clinicians at all levels, and across disciplines, will
support each other and provide regular
opportunities for debriefing in safe environments
Nurses and midwives, at all levels, will engage with
and contribute to policy development and
implementation
Nurses and midwives, at all levels, will engage with
and support the ethical conduct of research to
improve health outcomes and reduce risk. This
may include actively seeking out opportunities to
be involved in research
Nurse and midwife managers will create a supportive
environment that promotes research as a practice
improvement and continuous professional
development opportunity
2446
COMMENTARY
organizations (and managers) may contribute to the shift in clinicians’
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4
|
C O N CL U S I O N S
The conduct of research with vulnerable populations remains the subject of much debate, despite many now believing that to exclude vulnerable cohorts from research participation contributes to the
perception of them as vulnerable and further perpetuates their sense
of powerlessness.
This paper has provided experiential understandings upon which
to build and support future practice, policies and procedures in research
and clinical practice. It is imperative to conduct robust research to provide the evidence for continual practice improvement. Whilst serious
ethical consideration must be given to support studies that promote
the voice of the vulnerable in research and consider the circumstances
in context, they should not be excluded on the basis of their vulnerability. The justification for such considerations by nurses and midwives in
practice is apparent when the ethical principles are shown to be
embedded in both professions across both research and practice contexts. This highlights that the divide between building evidence and
operationalizing it may not be as wide as previously thought.
5 | I M P L I C A T I O N S F O R NU R S I N G
MANAGEMENT
This paper provides a rationale and guidance for nursing and midwifery managers to support research at the point of care ensuring that
the voices of the most vulnerable are heard in policy and practice
development and care provision.
E TH I CS S T A TE M E N T
Ethical approval was gained from the CQUniversity Human Ethics
Committee for the project that this commentary was based upon
(approval number: 0000021132).
ACKNOWLEDGEMEN TS
Open access publishing facilitated by Central Queensland University,
as part of the Wiley – Central Queensland University agreement via
the Council of Australian University Librarians.
DATA AVAI LAB ILITY S TATEMENT
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.
ORCID
Adele Baldwin
https://orcid.org/0000-0002-6325-4142
Tanya Capper
https://orcid.org/0000-0003-3464-1423
Clare Harvey
https://orcid.org/0000-0001-9016-8840
Eileen Willis
https://orcid.org/0000-0001-7576-971X
Bridget Ferguson
https://orcid.org/0000-0002-7440-3609
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How to cite this article: Baldwin, A., Capper, T., Harvey, C.,
Willis, E., Ferguson, B., & Browning, N. (2022). Promoting
nurses’ and midwives’ ethical responsibilities towards
vulnerable people: An alignment of research and clinical
practice. Journal of Nursing Management, 30(7), 2442–2447.
https://doi.org/10.1111/jonm.13764
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articles for individual use.
Received: 23 June 2022
Revised: 24 July 2022
Accepted: 11 August 2022
DOI: 10.1111/jonm.13764
COMMENTARY
Promoting nurses’ and midwives’ ethical responsibilities
towards vulnerable people: An alignment of research and
clinical practice
Adele Baldwin PhD, MNSt, RN, RM, Associate Professor1
|
Tanya Capper PhD, MMid, GradDipMid, L.LB, DipHEMid, RM, Head of Course,
Midwifery2
| Clare Harvey PhD, RN, BA, MA, Professor3
|
Eileen Willis PhD, MEd, BEd, Emeritus Professor4
|
Bridget Ferguson BNurs, MMid, GradCertMid, RN/RM, Lecturer5
Natalie Browning BA, MEd, BN/Mid, RN, RM, Associate Lecturer1
1
School of Nursing, Midwifery and Social
Sciences, CQUniversity, Townsville,
Queensland, Australia
|
Abstract
Aim: To stimulate discussion and debate about the inclusion of vulnerable popula-
2
School of Nursing, Midwifery and Social
Sciences, CQUniversity, Brisbane, Queensland,
Australia
3
School of Nursing, Massey University,
Wellington, New Zealand
4
Flinders University, Adelaide, South Australia,
Australia
5
School of Nursing, Midwifery and Social
Sciences, CQUniversity, Rockhampton,
Queensland, Australia
tions in primary research to inform practice change and improve health outcomes.
Background: Current research practices to safeguard vulnerable people from potential harms related to power imbalances may in fact limit the generation of evidencebased practice.
Evaluation: The authors draw on their experience working and researching with a
recognized group of vulnerable people, incarcerated pregnant women, to provide
insight into the application of ethics in both research and clinical practice. In a novel
approach, the ethical principles are presented in both contexts, articulating the syner-
Correspondence
Tanya Capper, School of Nursing, Midwifery
and Social Sciences, CQUniversity, Brisbane,
Qld 4000, Australia.
Email: [email protected]
gies between them. Suggestions are presented for how individuals, managers and
organizations may improve research opportunities for clinical practitioners and
enhance the engagement of vulnerable people to contribute to meaningful practice
and policy change.
Key Issues: Ethical practice guidelines may limit the ability to create meaningful
change for vulnerable populations, who need authentic system change to achieve
good health outcomes.
Conclusion: Inclusive research and practice are essential to ensuring a strengthsbased approach to healthcare and addressing health needs of the whole population.
Health systems and models of care recognizing the diverse lives and health needs of
the broader population demand practical, sustainable support from clinical managers.
Implications for Nursing Management: Practical suggestions for clinical managers to
support point of care research is provided, embedding vulnerable voices in policy,
practice development and care provision.
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