Fluent Essays

1 Qualitative data has been described as voluminous and sometimes overwhelming to the researcher. Discuss two strategies that would help a researcher manage and organize the data. 2 The three types of qualitative research are phenomenological, grounded theory, and ethnographic research. Compare the differences and similarities between two of the three types of qualitative studies and give an example of each. esearchSue Z. Green and Jennifer L. Johnson And whatever you do, in word or deed, do everything in the name of the Lord Jesus, giving thanks to God the father through Him —Colossians 3:17 (English Standard Version) Essential Questions · Why are ethical principles important when conducting research on human subjects? · What is the focus of qualitative nursing research in professional nursing practice? · What methodologies are used to conduct qualitative research? · Why should the BSN-prepared nurse critically appraise published research studies? · How does the BSN-prepared nurse critically appraise published research studies? Introduction · One of the hallmarks of any profession is a scientific research base. The nursing profession bases its practice on a solid foundation of evidence developed through research by nurses and results gleaned from multiple disciplines, such as psychology, social work, and medicine. Nurses are called upon to develop a safe practice that is grounded in evidence to promote positive health outcomes in the populations served.Nurses are called upon to develop a safe practice that is grounded in evidence to promote positive health outcomes in the populations served. The continued advancement of nursing research is critical for further development of the nursing profession. The process of conducting nursing research must be grounded in  ethics  and provide fair treatment of  human subjects . A proficient registered nurse must be knowledgeable about ethical principles that are required when conducting nursing research.  Through a variety of methodologies, nurse researchers study phenomena of interest to the profession. For example, a nurse wishing to determine the  causative factors  related to increased infection rates in patients with urinary catheters may study nursing care procedures for these patients. Likewise, a nurse may desire a deeper understanding of culture on health practices and design a study to learn about these influences.  Nursing is considered to be both an art and a science. The science component requires nurses to seek methodical, logical methods for choosing nursing process actions. In addition, nurses seek answers to practice questions through application of scientific inquiry or research. Researchers may design studies that are  quantitative  or  qualitative  in nature. Quantitative design is based on the traditional scientific research design and the science aspect of nursing. Through quantitative design, researchers are able to quantify findings easily. For example, a quantitative study designed to address infection rates will provide factual data about the number of infections occurring and other statistical data.  Through qualitative research methodologies, nurse researchers study aspects of the art of nursing. These may include lived experiences, feelings, and perceptions among other facets of the human experience. For example, the nurse researcher may design a study to learn more about the lived experiences of breast cancer survivors. This information can then be used to prepare the registered nurse to provide care to this population of patients. The baccalaureate-prepared nurse is a consumer of nursing research. In this role, the nurse accesses, appraises, and may participate in clinical research. This chapter will provide an overview of the ethical implications for qualitative nursing research as well as discussion about qualitative nursing research methodologies.  Nursing and Codes of Ethics Nursing is a profession grounded in ethical practice. Historical foundations of the nursing profession are deeply intertwined with ethical actions by those called to provide care for the sick, needy, and poor. Historically, nursing education curricula have included focus on the foundations of ethics, nursing codes of ethics from the American Nurses Association (ANA) and the International Council of Nursing, as well as the development of professional values as part of the essential elements of baccalaureate nursing education (American Association of Colleges of Nursing, 2008). The codes of ethics are used to guide professional nursing practice and role performance, including qualitative research. Nurse researchers are also guided by the Nuremburg Code, the Declaration of Helsinki, and the Universal Declaration of Human Rights in pursuit of ethical and safe nursing research (Kawar, Pugh, & Scruth, 2016; Schuster, 1997; United Nations, n.d.; World Medical Association, 2017). In addition to these guiding principles,  nurse scientists  are also responsible for adhering to federal, state, and local laws pertaining to research on human subjects (Mallari & Tariman, 2017). As part of the professional role responsibility, the BSN-prepared nurse should engage in the examination of emerging ethical issues in practice and take an active role in solving these dilemmas. The process of  ethical problem solving  is complex; the nurse must understand basic ethical principles in order to aid in principled decision making. The use of ethical frameworks and decision-making models can guide the nurse through ethical dilemmas. An approach to ethical dilemmas and nursing research that is evidence-based may contribute to patient safety and improved outcomes (Mallari & Tariman, 2017). To fulfill professional role responsibilities, the BSN-prepared nurse should be familiar with both the ANA Code of Ethics and the International Code of Ethics.  ANA Code of Ethics The first official nursing Code of Ethics was developed by the ANA in 1950 (Epstein & Turner, 2015). The purpose of the original ANA Code of Ethics was to provide a framework to guide professional nursing practice through competence and ethical behaviors. The current ANA Code of Ethics has been through multiple revisions since origination, with the most current version approved by the ANA in 2015. The modern ANA Code of Ethics describes the profession’s “values, obligations, duties, and professional ideals” (Epstein & Turner, 2015, para. 21). The ANA Code of Ethics is an important framework for the registered nurse to use when navigating complex situations and ethical dilemmas in the health care setting. The document is also used as a guiding framework when conducting qualitative nursing research. Provisions 1–3 address nurse and patient relationships, Provisions 4–6 address nurse boundaries of duty and loyalty, and Provisions 7–9 address professional commitments beyond patient encounters. The registered nurse must utilize this framework to develop a professional moral compass and deliver high quality, safe nursing care. In addition, the nurse researcher must apply principles from the ANA Code of Ethics when conducting any type of research. For example, Provision 1, human dignity, compels qualitative nursing researchers to adhere to the patient’s right to self-determination (see Table 2.1). Likewise, Provision 4, ethics encompassing duty and loyalty, fosters accountability expectations for the researcher. Table 2.1 Overview of the ANA Code of Ethics Applied in Qualitative Nursing Research ANA Code of Ethics Provision Application to Qualitative Nursing Research Provision 1: The nurse practices with compassion and respect for inherent dignity, worth, and unique attributes of every person. · Researchers must respect human dignity, relationships with patients, the nature of health, the patient’s right to self-determination. Provision 2: The nurses’ primary commitment is to the patient, whether an individual, family, group, or community. · Areas addressed include primacy of the patient’s interests, conflict of interest for nurses, collaboration, and professional boundaries. · The researcher’s commitment is to the subject. · Example: The nurse researcher should ensure a subject is comfortable when discussing the death of a child in a study focused on parental grieving. A private room and tissues would be provided by the researcher.  Provision 3: The nurse promotes, advocates for, and protects the rights, health, and safety of the patient.  · Areas addressed include protection or privacy and confidentiality for human participants in research, performance standards and review mechanisms, promoting culture of safety, and questioning unsafe and impaired practice. · The researcher is a patient advocate. · Example: The nurse researcher advocates for long-term counseling services to be made available to subjects in a study focused on surviving physical abuse after the study’s conclusion.  Provision 4: The nurse has authority, responsibility, and accountability for nursing practice; makes decisions; and takes action consistent with the obligation to promote health and to provide optimal care. · Areas addressed include authority, accountability, responsibility, nursing judgments/decisions/actions, assessment, and delegation. · The researcher is responsible and accountable. · Example: The nurse researcher determines that music therapy helped research subjects without improved mental health during chemotherapy treatment. To promote health, the nurse disseminates research findings in an appropriate manner. Provision 5: The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth. · Areas addressed include duties to self and others, promotion of personal health/safety/well-being, preservation of wholeness of character, preservation of integrity, maintenance of competency, and continuation of professional and personal growth.  · The researcher must take care of self. · Example: The nurse researcher takes time to self-reflect after interviews with subjects who have reported being perpetrators of crimes.  Provision 6: The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work settings and conditions of employment that are conducive to safe, quality health care. · Areas addressed include environment and moral virtue, environment and ethical obligation, and responsibility for health care environment. · Researcher promotes an ethical environment. · Example: The nurse researcher ensures that he or she is truthful in all communications with research subjects.  Provision 7: The nurse, in all roles and settings, advances the profession through research and scholarly inquiry, professional standards development, and the generation of both nursing and health policy. · Areas addressed include research and scholarly inquiry, developing/maintaining/implementing professional practice standards, and nursing and health policy development. · The researcher meets professional standards. · Example: The nurse researcher develops a study to learn about the lived experiences of refugees. The information is then used to influence nursing practice in the care of refugees.  Provision 8: The nurse collaborates with other health professionals and the public to protect human rights, promote health diplomacy, and reduce health disparities. · Areas addressed include health as a universal right, collaboration for human rights and diplomacy, and reduction of health disparities. · The researcher collaborates to protect subjects. · Example: The nurse researcher collaborates with a physician in designing a qualitative study to determine the impact of yoga therapy on the lived experience of patients with multiple sclerosis.  Provision 9: The profession of nursing, collectively through its professional organizations, must articulate nursing values, maintain the integrity of the profession, and integrate principles of social justice into nursing and health policy. · Areas addressed include articulation and assertion of values, integrity of the profession, integrating social justice, and social justice in nursing and health policy. · The researcher represents the profession through all interactions. · Example: The nurse researcher ensures fair and equitable treatment of all subjects. Subjects who are incarcerated are treated fairly in same manner as the public.  Note. Adapted from “Code of Ethics for Nurses,” by the American Nurses Association, 2015. Copyright 2015 by the American Nurses Association.  International Code of Ethics The International Council of Nurses (ICN) (2012) first approved the Internal Code of Nursing Ethics in 1953. The most current 2012 version serves as a framework to guide professional nursing practice and ethical decision making globally. Inherent in the ICN code is the focus on human rights, dignity, and respect. According to the ICN code, professional nurses, regardless of practice area, have four basic responsibilities including promoting health, preventing illness, restoring health, and alleviating suffering (International Council of Nurses [ICN], 2012). The four basic elements of the code’s framework include nurses and people, nurses and practice, nurses and the profession, and nurses and coworkers. Within each basic element, there are specific directives the professional nurse may use to guide decision making and action. For example, directives regarding nurses and people guide patient-centered care decisions and actions by nurses (see Table 2.2). Likewise, the nurses and coworkers element fosters an ethical, collegial environment. Table 2.2 Overview of the International Code of Nursing Ethics and Application in Qualitative Nursing Research International Code of Nursing Ethics Element Discussion of Elements Nurses and People · Patient-centered care, supportive environment, culturally appropriate care, meets needs of patients, advocates for social justice, and demonstrates professional values · Example: The nurse researcher will respect the individual differences between cultural groups in qualitative research. Differences are valued and explored.  Nurses and Practice · Responsibility, accountability, standard of care, good judgment, appropriate conduct, technology use, and ethical behavior · Example: The nurse researcher adheres to all standards of care and ethical foundations when designing and performing qualitative nursing research.  Nurses and the Profession · Implements professional standards, evidence-based practice, professional memberships, supports good work environment, supports protection of natural environment, and challenges unethical practices · Example: The nurse researcher uses evidence and professional standards when designing qualitative study to promote ethical practice and fair treatment of subjects.  Nurses and Coworkers · Collaborative, respectful work environments, safeguards individuals in the work environment if in harm, supports advancement of ethical conduct · Example: The nurse researcher adheres to ethical conduct in research study that is qualitative in nature and avoids misconduct. Note. Adapted from “The ICN Code of Ethics for Nurses,” by the International Council of Nurses, 2012. Copyright 2012 by the International Council of Nurses. Professional Values Ethics is defined as a set of moral principles (Ethic, 2018). Ethical behavior is fundamental to nursing practice to ensure optimal outcomes and patient safety, including nurse science and research. Nursing research ethics is important for protection of human subjects and safety of the public, which are critical points of professional nursing values. Consistent with the Christian worldview at Grand Canyon University, the nurse should seek, in all aspects of care, to pursue open dialogue, respectful interaction, and truth. When engaging in qualitative study, the nurse can learn about the lived experiences, thoughts, and feelings of others. There are times when this means nurses will engage with people who have differing viewpoints than those of their own. It is necessary to recall that although people may have different viewpoints and experiences, the nurse must treat all humans with dignity and respect. These approaches enable the nurse to provide care that is ethically sound and consistent with the values of the profession. Without attention to fundamental ethical principles, there is a possibility for research to cause undue harm. To conduct safe, ethical research, there must be an understanding of research ethics and basic ethical principles (Doody, 2016). The nurse must develop a working knowledge of the following ethical principles:  autonomy ,  beneficence ,  nonmaleficence ,  justice ,  veracity ,  fidelity , and  confidentiality  (see Table 2.3). Table 2.3 Foundational Ethical Principles Ethical Principle Meaning Example Autonomy A person has the right to self-determination; the right to make decisions in an autonomous manner A patient may decide to withdraw from a study about breast cancer survival after feeling depression. The nurse respects this decision. Beneficence The duty to do good; actions that are in the best interest of the patient The nurse researcher allows ample time after an emotional interview with a research subject for reflection and discussion to enhance outcomes for subject.  Nonmaleficence The duty to do no harm; actions to prevent harm to the patient The researcher purposefully keeps subjects separated in a study designed to look at relationships between survivors of domestic abuse and abusers.  Justice Moral obligation to act fairly The researcher ensures that all study participants have equal access to resources during a study, such as counseling and other services.  Veracity Truthfulness The researcher provides clear and truthful information to study participants. Subjects in a study focused on perinatal loss will understand this will be a topic of discussion in interviews.  Fidelity Keeping a commitment as stated to the patient; remaining faithful to commitments made The researcher remains faithful to commitments. If there are supposed to be a total of four field visits, the researcher ensures there are four total visits made.  Confidentiality Holding information in confidence appropriately The researcher holds all information in confidence as designed in the study. The privacy of HIV positive patients is protected in a study focused on the lived experience of HIV diagnosis.  Note. Adapted from Nursing Research: Generating and Assessing Evidence for Nursing Practice (3rd ed.), by D. F. Polit and C. T. Beck, 2017. Copyright 2017 by Wolters Kluwer Health/Lippincott, Williams & Wilkins. Check for Understanding 1. What vulnerable populations do you engage with as a nurse? Why are they considered vulnerable? 2. What is an example from your practice to demonstrate a patient’s right to self-determination? 3. What is the process for study approval in your agency?  4. What are the professional documents used by the nurse to guide ethical decision making? 5. What are examples of the ethical principles discussed in Table 2.3 that must be used in nursing research? 6. How should the nurse approach patients with diverse backgrounds and beliefs based on the Christian worldview at Grand Canyon University and professional nursing values? Quality and Safety in Qualitative Nursing Research · The nursing profession’s ultimate responsibility is to the public, those served through nursing care, to protect and practice safely. The professional nurse should understand the key principles involved in safe and ethical nursing research. These include human rights protections such as self-determination, privacy, anonymity and confidentiality, fair selection and treatment, and protection from discomfort and harm. Each principle will be discussed further to enhance understanding.  Human Rights and Protections Nurse researchers must recognize that human subjects are autonomous beings. Research subjects have the right to  self-determination . This right allows for the research subject to decide freely, without coercion, whether to participate in research study. The subjects can ask questions or decide to stop participation in a study at any time considering this important principle (Polit & Beck, 2017).  When considering research with human subjects, the researcher must understand the concept of  vulnerable populations . Ethical and human treatment is required for all research subjects; however, certain groups are at increased risk for harm during research. Groups that are vulnerable include children and pregnant women as well as people who are mentally or emotionally disabled, severely ill, physically disabled, terminally ill, and institutionalized (Polit & Beck, 2017). Because of increased vulnerability, special precautions and safeguards must be taken to ensure  informed consent  and safe nursing research practice with these groups. It is suggested that research be done with these population groups only when the benefit outweighs the risk (Polit & Beck, 2017).  Nursing research subjects must be guaranteed a right to privacy. Nurse researchers delve into personal health data when conducting research. Nursing research must be planned to collect needed data while being as unobtrusive as possible. Subjects must be assured that protected health information will be kept in confidence with privacy maintained (Polit & Beck, 2017). The concepts of anonymity and confidentiality are important considerations.  Anonymity  means the nurse researcher has no means of connecting data collected with the subject providing the data (Polit & Beck, 2017). An example of this would be distribution of a survey on fast food choices at a local restaurant. If the surveys were collected with no identifying data, they would be considered anonymous. The researcher would have no means of connecting the survey data with the subject. It is important to note that during qualitative study, anonymity is not usually achieved as the researcher and subject often have close and continued contact (Polit & Beck, 2017).  Confidentiality implies there is a promise the researcher will not publish any data in a manner that may demonstrate a connection between the data and the research subject (Polit & Beck, 2017). When conducting research, there may be data collected that connects the subject and findings; however, confidentiality implies this connection will not be shared through dissemination of research findings. For example, in a qualitative study focused on the behavior of cigarette smokers, a researcher will have field notes on interviews with the subjects. The notes should be properly coded with an identifier other than the subject’s name to protect privacy.  Research subjects must always be protected from harm and discomfort considering the basic ethical principle of nonmaleficence. Researchers must protect human subjects from unnecessary harm while conducting studies. Harm may occur in the form of physical, emotional, social, or financial means (Polit & Beck, 2017). There are different methods to ensure no harm, which include qualified researchers, ensuring informed consent, and oversight from institutional review board for study approvals and monitoring.  Informed consent is mandatory for safe, ethical nursing research. Informed consent means a research subject has been provided a high level of detail about the proposed study, and the risks and benefits, as well as an explanation that they may withdraw from the study at any point (Polit & Beck, 2017). In certain cases, there may be a waiver for informed consent including a finding from the institutional review board that a study is exempt from this requirement or in limited emergency settings (U.S. Department of Health and Human Services [HHS], n.d.).  Institutional Review Boards To ensure the highest protections are met in nursing research, studies should be approved and monitored by an  institutional review board (IRB) . The role of the IRB is to ensure protection of human subjects through ethical research methods. The IRB meets on a regular basis to review all applications for new studies and to discuss ongoing monitoring of studies. An initial review by the IRB will include review of all study protocols as written by the researcher, all consent forms and communications that will be provided to subjects, and discussion with the researcher for a question and answer period. In some cases, the IRB will require revision of study protocol and documents from the researcher.  An IRB should have at least five members, and (Polit & Beck, 2017), one of whom is not a researcher and one who is not affiliated with the agency. Also, the IRB should include a mixture of male and female members. The requirements of IRB review according to the federal government are as follows (Polit & Beck, 2017): · Risks to participants are minimized · Risks to participants are reasonable in relation to anticipated benefits, if any, and the importance of the knowledge that may reasonably be expected to result. · Selection of participants is equitable · Informed consent will be sought, as required, and appropriately documented · Adequate provision is made for monitoring the research to ensure participants’ safety · Appropriate provisions are made to protect participants’ privacy and confidentiality of the data · When vulnerable groups are involved, appropriate safeguards are included to protect their rights and welfare (p. 151) In some cases, a researcher may request an  expedited review  from an IRB. This type of review can be requested only when the study has been found to present very minimal risk of harm to the research subject. Expedited reviews are usually carried out by one person, usually the chairperson of the IRB (Polit & Beck, 2017). A researcher may also request that a study be  exempt  from IRB review, meaning there is no risk of physical or mental harm to the subject.  Research Misconduct It is important to address unethical practice in nursing research; thus, the nurse researcher must safeguard against  research misconduct . This is clearly defined by the U.S. Department of Health and Human Service’s Office of Research Integrity (n.d.) as “ fabrication ,  falsification , or  plagiarism  in proposing, performing, or reviewing research, or in reporting research results” (para. 1). The Office of Research Integrity (ORI) is tasked with oversight of all Public Health Service research. To address its mission, the ORI develops polices to ensure ethical research, monitors research, provides technical assistance to agencies conducting research, provides education about research conduct, and administers programs to support ethical behavior in research (Office of Research Integrity [ORI], n.d.). Qualitative nursing researchers must be aware of the elements of research misconduct and take measures to avoid actions that could be construed as misconduct (see Table 2.4). Table 2.4  Elements of Research Misconduct Applied in Qualitative Nursing Research Element Meaninga Example of Misconduct Fabrication Making up data or results and reporting or recording them · Creating records of subject interviews that were never performed · Making progress notes of meetings that never occurred · Preparing records for people who died during the study Falsification Manipulating research materials, equipment, or processes, or changing or omitting data or results such that the research is not accurately represented in the research record. · Falsifying the times for an interview in the study · Substituting one subject’s record for that of another · Altering dates and results from a subject’s visit Plagiarism Appropriation of another person’s ideas, processes, results, or words without giving appropriate credit. · Submitting another’s work as your own or not properly citing the original author Note. aMaterial republished from “Definition of Research Misconduct,” by the U.S. Department of Health & Human Services, Office of Research Integrity, n.d. Duty of Care · As a practice discipline and as part of the duty of care, professional nursing must develop evidence-based standards for care. One characteristic of a profession is a scientific research base that is continually expanding. Through safe, high-quality nursing research study, findings are beginning to be translated into care practices to improve the health outcomes of the patients nurses serve. The baccalaureate-prepared nurse is expected to be a consumer of nursing research. This means the nurse must understand how to access and analyze nursing research for applicability to practice. The baccalaureate-prepared nurse may participate in research studies as a team member to help create best practice guidelines. For example, many hospitals have nursing research teams to address areas of concern related to patient care outcomes on which the nurse may participate.  Evidence-Based Practice and Professional Role Responsibilities Critical Appraisal of Nursing Research The baccalaureate-prepared nurse should be able to complete a  critical appraisal  of a published research study. Critical appraisal is defined as the “process of carefully and systematically examining research to judge its trustworthiness and its value and relevance in a particular context” (Truluck & Leggett, 2016, p. 355). Through appraisal, the nurse can analyze the construction of the study, the methodologies, and the feasibility of application to nursing practice. This means the nurse can evaluate how the study is designed, the methods used in the study, and determine if the findings can be used to improve nursing practice. “Critically appraising the literature is necessary to inform evidence-based practice” (Truluck & Leggett, 2016, p. 356). There are many tools available to guide the nurse through the process of critical appraisal of nursing research; however, there are three main questions to ask: · Are the results of the study valid? · What are the results? · Will the results help improve care for my patients? (Truluck & Leggett, 2016; Wilkins, 2016) The first question, which addresses validity, aims to determine whether the researcher used appropriate methods when completing the research. In other words, it should be clear upon review that the study was designed properly, approved by an IRB, used appropriate measures, and was ethical in nature. The more well-designed and sound a study is, the more valid its results will be. A study designed with a high level of rigor, or standards, should produce results that are trustworthy and valid (Wilkins, 2016).  The second question addresses the actual study findings. For example, the baccalaureate prepared nurse should analyze study findings and determine whether the results were statistically significant and if similar results would be found if the study were replicated (Wilkins, 2016). The last question addresses applicability to professional practice. The BSN-prepared nurse should consider whether the findings would be relative to populations served and if the risks outweigh the harm (Wilkins, 2016). This is often identified through general questions the baccalaureate-prepared nurse should include in a critical appraisal.  Critically Appraisal of Published Research According to Truluck and Leggett (2016), questions to include in the general critical appraisal when reading the article are:  1. Is the study question relevant? 2. Does the study add anything new? 3. What type of research question is being asked? 4. Was the study design appropriate for the research question? 5. Did the study methods address the most important potential sources of bias? 6. Was the study performed according to the original protocol? 7. Does the study test a stated hypothesis? 8. Were the statistical analyses performed correctly? 9. Does the data justify the conclusions? 10. Are there any conflicts of interest?  It is important to note that the usefulness of critical appraisal in qualitative research has been questioned (Truluck & Leggett, 2016). Most critical appraisal tools are formulated to analyze quantitative studies and may not be best suited for qualitative research, which focuses on feelings and perceptions (Truluck & Leggett, 2016).  Critical Appraisal of Qualitative Research Articles According to Patterson and Dawson (2017), questions to include in the appraisal of a qualitative study during initial reading include: 1. Is there is clear statement of the aims of the research? 2. Are the methods and design appropriate to the research question? 3. Is the recruitment strategy and sampling appropriate? 4. Is the method of data collection fully described and justified? 5. Have ethical considerations been described? 6. Does the study have sufficient validity, reliability, and rigor? 7. Is the data analysis sufficiently robust? (pp. 123-125) The Critical Appraisal Skills Programme (CASP) provides a rapid critical appraisal tool that is useful for the nurse. This online resource provides free training for health care professionals to learn the skill of rapid critical appraisal for nursing research. The site provides free printable, downloadable checklists for a variety of study types, including qualitative nursing research. The online resources and tools are available at the CASP website (Critical Appraisal Skills Programme, n.d.).  In addition to the questions suggested, there are other general factors to consider when appraising nursing research. These include, but are not limited to, general relevance to nursing practice, currency of references, disciplines of authors, level of evidence used, databases used, and strength of the synthesis of data. For example, the nurse must not only access and review current nursing literature, but also consider its applicability to nursing practice. A nurse may review an excellent qualitative study on health care access for patients in urban areas, but if the nurse is practicing in an isolated rural area, some of the concepts of this research may not be applicable to his or her practice. The nurse should evaluate all reference citations within an article. Upon this review, references should generally be no older than five years unless they are considered to be classic articles of significance. Articles should cite credible sources as references including peer-reviewed journals, textbooks, or credible Internet references. Other factors included in the analysis of a research article include the expertise of the researcher, support of funding for the study and ensuring all ethical principles previously discussed have been applied. Databases that are appropriate for supporting nursing research include, but are not limited to, CINAHL, Cochrane, PubMed, National Institute of Health (NIH) or other government-based sources, ProQuest, and Ebsco. College libraries have software that sort through certain databases for published, peer-reviewed research articles related to search terms. · The profession of nursing must continually evolve. The BSN-prepared nurse can contribute to the continued development and improvement of the profession through positive attitudes toward implementation of evidence-based practice (Brower & Nemec, 2017). Through questioning current practices, accessing and appraising nursing literature, and proposing solutions to current practice problems, the professional nurse can impact health care outcomes in a positive manner (Brower & Nemec, 2017).  Components of Publishing Research Dissemination of nursing research is needed for continued expansion of the scientific research base. Research that is conducted should be shared. Dissemination of nursing research is needed for continued expansion of the scientific research base. As a generalist, the baccalaureate-prepared nurse is prepared to participate in conducting research studies as a team member. While the baccalaureate-prepared nurse is not expected to design and lead a study, he or she may serve as research team member to assist in carrying out study protocol. Being a contributor to published nursing research is one outcome for nurses who participate on research teams, which means that the baccalaureate-prepared nurse should be familiar with structure and required elements for publishing nursing research articles in peer-reviewed journals. While nursing journals may have some variations in the requirements for manuscript formatting, the general structure of nursing research articles will be reviewed in this chapter. Many journals require what is referred to as an IMRAD (Introduction, Methods, Results, and Discussion) format along with an abstract and reference list (Polit & Beck, 2017). The nurse should also be aware of important areas of focus for nursing research. The National Institute of Nursing Research (2016) has identified the following areas of focus for continued nursing research in its strategic plan:  · Personalized health strategies · Promoting health and preventing disease · Improving quality of life for people with chronic disease · End-of-life and palliative care · Technology use in improving health care · Innovative strategies for nurse research career development An  abstract  provides a brief overview of the study, usually in 250 or fewer words. The abstract should provide the reader with an overview of the background, objectives, methodology, results, and conclusions in a succinct paragraph. An  introduction  should follow the abstract and provide background information and establish relevance. Elements that may be addressed in this section include the issue of focus, population of interest, current evidence, theoretical framework, purpose of the study, the research question, and reason why the study is needed. The  methods  section addresses the specific approaches or methodologies used by the researcher when conducting the study. Items included in this section include the design of the study, how sampling was decided upon, how data was collected, instruments used, how data was analyzed, and general study procedures, including how subjects were safeguarded. The  results  section of an article should address study findings in a detailed manner. If statistical tests were used in the study, detailed findings should be shared including names of tests used, value of statistical data and the significance of the findings. It is important to note that statistical tests are not often used in qualitative nursing research. Frequently, instead of sharing statistical data in this section, qualitative researchers will include excerpts from participant interviews for an article. Lastly, in the  discussion  section of the article, nurse researchers discuss interpretation of findings. This involves drawing conclusions about the findings, discussing study limitations and applicability to practice, and calling for further study on the topic.  Check for Understanding 1. Review a journal article and ask yourself at least three of the questions presented in this chapter for critical appraisal.  2. What is the purpose of critical appraisal? Overview of Qualitative Nursing Research Qualitative Research Study Design Qualitative nursing research tells a story; it is a developing narrative that reflects realities and viewpoints of study subjects. Key characteristics of a qualitative study as identified by Polit and Beck (2017) include: · Flexible, capable of adjusting to new information during the course of data collection · Holistic, aimed at an understanding of the whole · Involves merging various data collection strategies · Requires researchers to become intensely involved · Relies on ongoing analysis of the data to formulate subsequent strategies and to determine when data collection is done. (p. 463) Qualitative researchers identify a study design early in the research process. There are various methods that may guide qualitative nursing research (see Figure 2.1).  Ethnography  is a method aimed at examination of cultural behaviors. Researchers using ethnography seek to understand cultural behaviors and the reasons behind them on a deeper level. The researcher may deeply immerse themselves in the culture being observed. Data is often collected through participant observations and key informant interviews (Polit & Beck, 2017).  Phenomenology  provides an approach that allows researchers to better understand a person’s lived experiences. Through this method, researchers attempt to gain a deeper understanding of significant phenomena in life. Data is usually collected through extensive interviews and conversations with study subjects. Sample sizes are generally small when this methodology is used (Polit & Beck, 2017).  Grounded theory  is an approach that allows for researchers to consider phenomena of significance to nursing. The aim is to understand actions taken in an area by those who are involved in performing the actions. This methodology has led to the development of many middle-range, or narrower, practice-related nursing theories (Polit & Beck, 2017). In some cases, researchers may not identify a study design as one of the designs mentioned. This type of study is often referred to as a  descriptive qualitative  study design (Polit & Beck, 2017). Often, these studies are a meshwork of other types of study designs.  Case study  design allows for review of relationships between phenomena or trends over time. There is deep investigation centered on a single entity or focus (Polit & Beck, 2017).  Narrative analyses  focus on storytelling through the lens of culture. This methodology is designed on the premise that people interpret experiences and tell them through stories. The researcher using this methodology seeks to make meaning out of the stories told (Polit & Beck, 2017). Sometimes researchers design a study to include both qualitative and quantitative methodologies. This type of study design is referred to as  mixed methods  research.  Outcomes research is common in health care with an emphasis on assessing outcomes of patient care and using that data to improve health care provision (Agency for Healthcare Research and Quality [AHRQ], n.d.). This approach may involve the measurement of both quantitative and qualitative data. For example, data obtained through outcomes research may include quantitative data, such as mortality rates and qualitative data measured through patient satisfaction surveys. This area of research is growing in popularity and is described as the way to know what is happening in health care and how to determine measures to improve health care (AHRQ, n.d.).  Research Synthesis Nurse researchers often have need to conduct extensive review of existing literature; this is broadly identified as research synthesis. Through a process referred to as  systematic review , the nurse researcher conducts a structured review of existing nursing research on a selected topic. This process is identified as critical to the continued development of the nursing profession and evidence-based practice (Polit & Beck, 2017). A systematic review is more extensive and detailed than a simple literature review. This approach is used in qualitative research and may be referred to as  metasynthesis  (Polit & Beck, 2017). The process of metasynthesis is especially important for qualitative research, as one of the criticisms of this methodology is the concern about lack of generalizability of the findings (Polit & Beck, 2017). Because qualitative design often has a more flexible design approach, critics may argue that the research findings are less valid and thus not as readily applicable to larger populations. The process of metasynthesis allows for a larger grouping of qualitative data to review for commonalities. Identifying these commonalities in research findings supports the idea of generalizability to the larger population.  Qualitative Research Methodologies Methodologies used in qualitative design may vary from quantitative study because of the different focus and aims of the two approaches. Selection of study participants, or  sampling , is an important area for consideration. When selecting study participants, the qualitative researcher seeks to find subjects who can enrich understanding of the issue studied. Questions the researcher may ask when recruiting subjects include, “who can confirm my understandings, challenge or modify my understandings, enrich my understandings?” (Polit & Beck, 2017, p. 491). Key concepts that differentiate sampling in qualitative study rather than the probability sampling associated with quantitative study include smaller sample sizes, lack of random sampling, and emerging sample selection (Polit & Beck, 2017). Various types of nonprobability sampling methods may be used in qualitative study (see Figure 2.2). These include convenience sampling, snowball sampling, and purposive sampling.  Convenience sampling  is also referred to as volunteer sampling. Subjects present themselves, or volunteer, for participation in the study. While considered an easier method of sampling, it can present concern for the researcher. In some cases, the sample may not produce the desired results or information (Polit & Beck, 2017).  Snowball sampling  involves study participants referring other participants to the researcher for inclusion in the study. The effect is that the sample size snowballs or increases in size. This method may help the researcher develop a more desirable sample with less risk of bias.   Purposive sampling involves selection of subjects who are of benefit to the research focus (Polit & Beck, 2017). In other words, the subjects are recruited because the researcher believes the subjects’ data will enhance the findings of the study. For example, if a researcher is designing a study to address the lived experience of breast cancer survivors, he or she may visit a breast cancer support group to recruit subjects. Regardless of sampling method used, it is important to understand the concept of  data saturation  in qualitative research. This refers to the idea that the researcher will continue with sampling and data collection until there is a point in which no new findings are discovered (Polit & Beck, 2017). Once data saturation has occurred, the research using qualitative study design will move to analysis of the data.  Figure 2.2 Comparison of Sampling Techniques Data is collected in a qualitative study in a variety of ways (see Table 2.5). For example, a qualitative study with subjects experiencing childbirth may be interviewed, asked to journal about their experiences, or both. It is important to note that in qualitative studies, the process of data collection generally requires a higher level of flexibility and fluidity than that of quantitative nursing research (Polit & Beck, 2017). The researcher often conducts field visits and may meet with a subject more than once. This means the process of qualitative research evolves as the process is carried out. Because of the nature of this type of study and the aim of the research, it is important for the researcher to build trust with subject participants during data collection processes. Another important consideration for the researcher is to safeguard against emotional attachment to the study subjects (Polit & Beck, 2017). Because of the in-depth nature of this research design, researchers and study participants spend an increased amount of time together discussing intensive personal thoughts and feelings. The researcher must be aware of this risk and take precautions to avoid this from occurring by maintaining professional boundaries and adhering to professional standards of practice and the nursing codes of ethics previously discussed.  Table 2.5 Qualitative Research Data Collection Methods Data Collection Method Description Interviews · Structured or unstructured · Involve specific questions derived from the research questions established for the study · Transcripts of conversations needed Focus Groups · Group of people, usually at least five, assembled for discussion · Popular in health-related research · Interviewer is moderator · Interviewer has a set of questions to ask or topics to discuss · Transcripts of conversations needed Diaries and Journals · Format may be unstructured or structured to address certain issues · Good for historical review and learning about subject experiences/feelings Observation · Observing participants in the field during times of social interactions · Daily notes recorded in field logs Note. Adapted from Nursing Research: Generating and Assessing Evidence for Nursing Practice (3rd ed.), by D. F. Polit and C. T. Beck, 2017. Copyright 2017 by Wolters Kluwer Health/Lippincott, Williams & Wilkins.  Check for Understanding 1. What type of qualitative study design would be best to study cultural implications on health?  2. What is data saturation, and why is it important?  3. Why are transcripts important from subject interviews in qualitative design? Future of Nursing and Trends · Outcomes research is a developing trend in health care, including nursing research. Nurses are on the forefront of health care. Through careful analysis of health care provision, risks, policy, and evidence; nurses can create and use data to help transform health care. The development of a sound scientific research base in a hallmark of any profession. Nurses of all educational preparations are expected to develop practice that is grounded in the best evidence available. To continue to advance nursing as a profession, each nurse must embrace the development of practice that is evidence based.  Reflective Summary In terms of the future, the nursing profession brings a “steadfast commitment to patient care, improved safety and quality, and better outcomes” (Institute of Medicine, 2011, p. xi). With the passage of the Affordable Care Act in 2010, nurses have been called upon to be leaders on the forefront of health care improvement and change. Upon review of professional standards, such as the ANA Code of Ethics, nurses are expected to be consumers of research. Through continued focus on building profession practice upon a scientific base of evidence, the BSN-prepared nurse can positively impact health care outcomes on a broad scale. There is a need to consider unique approaches to addressing the complex problems seen in the population served by the health care system. Nurses are called upon to lead these efforts through recognizing clinical problems, asking questions, developing and participating in nursing research, appraising current evidence and translating evidence into professional practice. The BSN-prepared nurse must develop an appreciation and understanding of nursing research to develop a best-practice approach to providing safe, high-quality, professional nursing care. Chapter  7: Human Experimentation  Section 4. Readings The Ethical Considerations of Medical Experimentation on  Human Subjects  by Manny Bekier, M.S.  November 18, 2010 A critical examination of the ethics of medical experimentation on human subjects, focusing on the medical experiments conducted on human subjects by the doctors in Nazi Germany, as well as, in post-war U.S. may contribute to a greater effort to curb potential abuse. In this endeavor, it is necessary to understand the prevailing principles that guided the medical profession in Nazi Germany in pursuing their heinous actions.  Why is this so relevant today? After all, this happened in the past, and not even in the U.S., an aberrant culture created by a totalitarian regime over 65 years ago that no longer exists. Will such an examination help in confronting biomedical issues today?  In 2010 United States Secretary of State Hilary Clinton apologized for syphilis and gonorrhea experiments conducted on Guatemalans between 1946-1948 without their knowledge or permission. These experiments involved 696 subjects, male prisoners and female patients in the National Mental Health Hospital of Guatemala. What is especially shocking is the fact that 60 years later the public learned about these unethical experiments co-sponsored by the U.S. Public Health Service, the NIH, the Pan American Health Organization and the Guatemalan government:  . The fact that these experiments were considered, approved and initiated only a year after the trial of the Nazi doctors and their dreadful experiments on human subjects, makes this subject especially relevant.  Dr. Arthur Caplan, a noted medical ethicist stated at a biomedical ethic conference,” The whole discipline of biomedical ethics rises from the ashes of the Holocaust”. (Robert Leiter, Tainted Science, Jewish World, July 14-20,1989). When we examine these past events, do we have the right to sit in judgment and make moral pronouncements?  The relevance for today cannot be overstated. In looking over the many documents available today, we might want to consider first whether we can make the argument that we are in a position to make retrospective moral judgments. Can we retroactively sit in judgment of the doctors who performed medical experiments on prisoners in the concentration camps?  These crimes were so enormous and so grossly immoral that they should not be so casually dismissed by citing some principle reflecting cultural ethical relativism (i.e. “you can’t judge people of that time, in that place, by our standards today”; - “there was a war going on and a suspension of normal rules are to be expected”). Can we simply state that since there was a war putting Germany in danger, extraordinary means were justified? Many people today might agree that extraordinary danger excuses extraordinary means to serve the common good. Despite the fact that such a belief totally rejects human rights, one is prevented from offering any judgment of these actions according to the principles of cultural ethical relativism.  The position one takes on retrospective moral judgment has serious implications on what one should be doing today. If one cannot judge that human rights were seriously violated in Nazi Germany, one cannot argue that human rights are being violated today. If morality is to have any validity today, clearly the arguments of cultural ethical relativism should be totally rejected.  Alan Buchanan states that there can be no moral progress unless we are able to apply the same moral yardstick to the past and the present. The passage of time does not affect the validity of moral judgment (Ronald Munson, Intervention and Reflection, p. 525). The fact that 65 years have passed does not diminish the evil manner in which the Nazi medical experiments were conducted.  The American Nuremberg Military Tribunal judged some of the key doctors.  (The Nuremberg Trials).  Some may wonder what is one to gain by issuing judgments of culpability? Shouldn’t this energy be focused on the future? Shouldn’t efforts be made to ensure that these wrong doings do not occur again? As Allan Buchanan stated, it would be a serious mistake to assume the choice must be to either make judgments of culpability or to focus on future prevention. (Munson,   p.530).  The Nuremberg Code of 1947 came into being as a result of the heinous human experimentation performed by the Nazi doctors in the many concentration camps throughout the German Third Reich. The judgment by the war crimes tribunal, as a result of the “Doctors Trial” at Nuremberg, established 10 principles to guide physicians in all human experimentation:  . Prior to the Nazi war crimes tribunal, there was no written international code for doctors. Lawyers defending the Nazi doctors pointed to events in the U.S., attempting to argue, for example, that similar wartime experiments were conducted with prisoners at the Illinois State Penitentiary, who allegedly, deliberately infected prisoners with malaria  .  The experience of the Nazi medical experiments performed in the concentration camps has made it painfully aware that medical experiments on human beings need to conform to well-defined ethical standards and should supersede the justification that such experiments may yield results for the “greater good of society” that might not be obtained by other methods or means of study. The first principle of the Nuremberg Code clearly states, “The voluntary consent of the human subject is absolutely essential”. This is followed by an explicit clarification of all the associated requirements, making it extremely difficult for research principle investigators to twist it’s meaning:    For an informed consent to be considered ethically valid, there must be full disclosure. This entails that the potential participant must be thoroughly informed as to the purpose of the research, the procedures to be used, the benefits to the participant, if any, and the potential risks and discomforts of participating in the research. Any deception jeopardizes the integrity of the informed consent process. There should also be assurances of confidentiality or anonymity of the participant. The participant's consent to participate in the research must also be voluntary and free of any coercion. It is vital that the participant understand what has been explained and be given the opportunity to ask questions. It is also necessary that the participant be competent to give consent. In the absence of competency, a legally approved advocate may provide consent. Participation in the research study should be authorized, preferably in writing. Everything should be clearly stated in an informed consent document, written in an easily understood format that avoids or explains technical terms, and whom to contact with further questions:  . The principles established by the Nuremberg Code for medical practice were modified and somewhat weakened in less than a year by the Declaration of Geneva, by modifying consent from "absolutely essential” to "if at all possible." Now doctors were given the latitude to obtain consent “if at all possible” and research was allowed without consent where proxy consent was given (Article II.1) Over the years the regulation of medical research continued to evolve. The World Medical Association adopted the Declaration of Helsinki in June 1964. Since then it has undergone various revisions, the last one, sixth revision, in October 2008. No doubt there will be a further evolution of ethical guidelines as new issues in research develop:  .  Looking at the medical experimentation performed on human beings under the Nazi regime, one will begin to understand why the effort was made to develop the Nuremberg Code, and the rationale for holding the participating doctors accountable for their actions. In reality the medical experiments conducted by the Nazi doctors were only a small part of the grand scale of systematic medical killing of the Third Reich. (Robert J. Lifton, The Nazi Doctors, New York: Basic Books, 1986, p. 269).  The Subjects  All records indicate that the subjects (prisoners) did not consent to any of the experiments. In many cases, experiments were performed by unqualified persons and under the most horrendous physical conditions. All of the experiments were conducted with no thought or precautions to the wellbeing of the subject from the possibilities of injury, disability, or death. In virtually all the experiments the subjects experienced extreme pain, resulting in permanent injury, mutilation, or death:  .  The Doctors  The Medical Case, the first of twelve Nuremberg proceedings, began on October 25, 1946. Twenty-three physicians, scientists, and other senior officials in the Nazi medical administration were put on trial. Seven of the accused were sentenced to death and executed; nine were given prison sentences; and seven were acquitted. Several major perpetrators were able to evade prosecution:  .  These twenty-three physicians hardly reflect the many medical participants conducting unethical medical experiments during the Third Reich. The majorities of the doctors were able to evade punishment and simply vanished, or, as in most cases, were reabsorbed into the medical community to continue their practice. The trial documents and evidence related to this case amount to approximately 2800 documents and 13,000 pages of material:  .  The prosecuting attorney at the Nuremberg Trials, General Telford Taylor expressed it succinctly, “This policy of mass extermination could not have been so effectively carried out without the active participation of German medical scientists.”  .  Who were these doctors, what influenced their thinking and how did they justify their actions in which they turned themselves from healers into murderers? When one considers Nazi medical experimentation, the name of Dr. Mengele is the name that most often comes up. Although he performed ghastly experiments on nearly 1,500 sets of imprisoned twins at Auschwitz and is considered by many, the most notorious of the Nazi doctors, he was hardly alone. He was not even the highest-ranking physician at Aushwitz (SS captain Dr. Eduard Wirths was the physician in charge at Auschwitz):  . Dr. Mengele M.D., PhD was hardly the crazed mad scientist portrayed in the motion picture The Boys From Brazil.  The medical profession in Germany, until several decades ago, attempted to cover-up the role played by the Nazi doctors rather than trying to understand what had happened and how it was allowed to happen, and the subject has remained taboo.  Attempts were made in the post war years to characterize these doctors, as a lunatic fringe, on the fringe of the medical profession. We were presented with myths of incompetence, madness on the part of a few, and coercion. William Shirer (author of The Rise & Fall of the Third Reich) described the Nazi doctors as  “irrational psychopathic butchers” on the fringes of professional medicine (W.L. Shirer, The Rise and Fall of the Third Reich, Greenwich, Conn: Fawcett, 1962). In reality, these doctors were not madmen, nor insane and this is why it requires critical examination of the medical profession to understand their behavior. It would be irresponsible to simply caricaturize the Nazis doctors and scientists as mad, irrational or devoid of conscience. These doctors, many of whom, were the leading professionals in their fields, were highly regarded by their peers throughout the world. It was some of these internationally recognized doctors who were in the forefront of giving credibility to Nazi racist theories.  The Thinking  How does one explain the attraction to National Socialism? 45% of the physicians in Germany became members of the Nazi Party. This was the highest ratio of Nazi party membership of any profession. By 1942, more than 38,000 doctors joined Nazi Party (almost 50%). The attraction was the biomedical vision with its emphasis on biology, research support, as well as, career opportunities.  The Nazi biomedical vision included the belief that certain “races” are superior to others; that scientific management could solve social problems (preventing the propagation of the “unfit”); the conviction that mental illness justified compulsory sterilization, and the measure of individual worth be in economic terms (reduce the cost of the defective or non-productive population). The overall vision was a lofty one: to improve the genetic composition of their citizenry in hope of creating a society in which individuals would be economically useful. These beliefs reflected basic utilitarian moral principles.  The rationale of these utilitarian principles can best be illustrated by examining the text of a speech by Dr. Walter Groß, the head of the Nazi Party’s Office of Racial Policy (October 13, 1934). “A single mentally ill Negro of English citizenship lived for 16 years in an institution in Berlin, costing 26,000 Marks. 26,000 Marks were thrown away on a life that had no meaning. 26,000 Marks that could have been used to prepare a dozen strong, healthy, and gifted children for life and a job. We went so far as to put the sick and the dying before the young, strong, healthy and promising. That is against nature and life. A nation going this way is heading for the abyss.”  . With these utilitarian principles, the Nazi government was able, through their T4 program, to euthanize (a euphemistic term meaning “good death”) at least 5,000 physically and mentally disabled German children. These children were categorized as “life unworthy of life” (one of many Nazi euphemisms justifying murder):  . The Office of Racial Policy was also prepared to rebut any arguments postulating divine law or natural law. In the same speech Dr. Groß, delivered the Nazi perverted perspective of natural law,“It is true that we are subject to a higher power. We humans may never interfere with the great laws of the Creator. But you are wrong. See the laws the Creator has established for his world and your life. The great law is that life must be able to preserve itself, and that if it cannot, it will collapse. It is the hard, brutal law of the struggle for existence and of selection and extinction.” .  To gain insight into the ethical issues that prevailed, it is necessary to understand the evolutionary ethics that prevailed in Nazi thought. Rudolf Hess, the Deputy Führer, came right to the point when he described National Socialism as “nothing but applied biology” (Lifton, p.129). This kind of thinking did not originate with the Nazis. This “biomedical vision” has a long history:  . This can best be understood by reading this medical interpretation of the Nazi ideology in which Germany was viewed as being ill and Hitler was sent as the doctor. (Please note the euphemism of the enemies within as “bacteria”). “When the Führer took power in 1933, the German people’s body was severely ill. The poison of foreign worldviews ran through the veins of all the people’s organisms. Hardly anyone was immune. Then Providence sent the German people a doctor, the Führer. He knew the disease; he knows the German people suffered from a corruption of its racial strength. Using every possible medication, including if necessary the most radical, the bacterium was removed from the people’s body. Our people are becoming racially healthy once more.”  .  It is interesting to note that natural law was considered central to the legal theory for the prosecution of these Nazi doctors during the Nuremberg trials. Natural law is a view that certain rights or values are inherent in, or universally recognized, by virtue of human reason or human nature. Since natural law, whose guiding principles are set by nature, are considered self-evident and have validity everywhere, the prosecution felt that it could serve as the standard to criticize the laws established by the Nazi regime. The prosecution had to rely on natural law theory because most of the actions of the Nazi doctors were recognized as being legal under the judicial system of the Third Reich. In fact, the Nazi defendants claimed they were merely following the established laws of the nation. They were not killing by their own authority, but obeying the laws of the state, which can determine the method of death. Even if a law is viewed as repulsive, one cannot deny legality. The law is no less legitimate as law merely because people find it morally reprehensible:  .  In addition to claiming they were acting within the law, the Nazi doctors justified their actions by what they considered to be moral reasons. To mention a few: law takes precedence over ethics; the good of the many is more important than the good of the few; national emergencies supersede ethics; to improve society by social engineering based on eugenic theories; some groups can lose their claim to humanity; some people were sub-humans (racially inferior) and were equated with vermin; Jews were a threat to society and the family.  The Ethics  All medical research had a purpose and ultimately was designed to help the German military effort, such as developing new weapons, testing pharmaceuticals and aiding in the medical treatment of military personnel who had been injured, as well as advancing the racial ideology of the Nazi regime:  . Consequently, the doctors during the Nazi regime felt that they were doing wonderful work for humanity. This raises a critical issue. The doctors in Germany took the Hippocratic Oath, yet they knowingly violated the Hippocratic principle of “do no harm”. How were they able to reconcile this glaring contradiction?  To begin to address this contradiction, an examination must be made of some of the moral premises utilized. One of the premises already cited was the exclusion of some ethnic groups’ claim to humanity. In Nazi Germany, Jews were, through a series of laws known as the Nuremberg Laws, methodically excluded from society, becoming non-persons.  The racial policies developed had a strong grounding in genetics and evolutionary biology. One need only look at some of the many written explanations by the Nazi government to prevent offspring with hereditary illnesses.“In the case of plants and animals cultivated by humans, care is taken to weed out the less valuable. Only the useful and valuable genetic material is preserved. That is also what nature wants through the law of selection. Should not we do the same with people? Or shall the lines of our people with hereditary illnesses overcome the healthy? That would mean the self-dissolution and destruction of the whole people, for a people that suffers from hereditary illnesses is not able to maintain itself in the great battle of selection between the peoples!  To protect the healthy population from the dangers of hereditary illness and dissolution, the National Socialist State created the “Law for the Prevention of Offspring with Hereditary Illnesses “ of 14 July 1933. Under this law, the genetically burdened are sterilized for the following diseases…”  .     In line with this thinking, prisoners were not viewed as individuals, but rather as “living culture” or rats, to be used with no consideration for wellbeing. In most cases, rats were treated far better than Jewish concentration camp inmates. In equating Jews with rats, a propaganda film by Fritz Hippler, The Eternal Jew, was made to show Jews as a dangerous parasitic race spreading disease. In this film, images of rats are juxtaposed over derogatory images of Jews. The narrator explains the Jews' rat-like behavior, while showing footage of rats squirming from sewers:  .  Since the doctors in Nazi Germany were guided by utilitarian moral principles, they did not need to consider informed consent. The utilitarian moral code has no need to consider informed consent. If more social good was to be gained without securing agreement, that was all that matters and was viewed as morally legitimate (Munson p.492). Utilizing utilitarian principles, Nazi Germany had no difficulty designating the mentally retarded, habitual criminals, the physically handicapped, patients with chronic diseases, as those less valuable members of society, referred to as “life unworthy of life”, and they could be legitimately sacrificed to improve life for the majority of the population. It is interesting to note that the definition of mentally retarded and undesirable was expanded over time to include anyone opposed to the Nazi regime.  According to Kantian principles (the categorical imperative), people cannot be forced to accept treatment or be subject to medical experimentation for “the good of the majority”. The Kantian view states that people should always be treated as “ends”, and never as “means” only. Therefore it is implicit with Kantian principles that a society cannot use a part of the population as slaves, as this treats them merely as means. By exploiting a part of the population for the gain of the rest, or even to exploit a single individual would reflect utilitarian principles. The medical experiments performed by the doctors in the concentration camps were predominantly utilitarian in nature. It should be noted that not one of the prisoners voluntarily waived their rights as human beings in order to sacrifice themselves for the alleged greater good of German society. That option was never a consideration, as the prisoners were considered “less than human”.  The Experiments  Between 1939 and 1945, at least seventy medical research projects involving cruel and, often, lethal experimentation on human subjects were conducted in Nazi concentration camps:  . There were a great many doctors at so many concentration camps performing a wide range of medical experimentation. For a brief description of these doctors and the medical crimes they committed, see:  .  In addition to the infamous Mengele’s medical experiments on twins, there were freezing experiments, high altitude experiments, malaria experiments at Dachau and Aushwitz; muscle and nerve regeneration, bone transplantation experiments, and sulfonamide experiments at Ravensbrück concentration camp; mustard gas experiments at Sachsenhausen, Natzweiler; sea water experiments at Dachau; sterilization experiments at Auschwitz, Ravensbrück and other places; and experiments with poison and phosphorus burn experiments at Buchenwald. For a comprehensive list of the medical experiments and other medical crimes, see the indictments (Oct. 25, 1946) of the Nuremberg Military Trial Case 1:    Also see:  .  The Nazis’ experiments on human subjects are well documented. There were so many doctors, at so many camps doing a wide range of cruel, unethical experiments. Even medical students were afforded the opportunity to practice and operate on people, regarding their specialty. One can imagine, for the research scientists and sponsoring pharmaceutical companies, this was paradise. Imagine having an endless supply of “live human materials” on which to test any medical hypothesis.  The results of many of these experiments were not exactly a secret. Findings were regularly published and distributed to the German medical profession and in a number of postwar scientific publications. In fact there is an abundance of documentation on these experiments. This paper will only focus on two types of experiments, as they are examples of ethical issues related to post-war experiments conducted in the U.S. and ethical issues we are still confronting today.  Citing first, the Freezing / Hypothermia experiments done at Dachau, as society was presented with the ethical issue of utilizing the medical data from these experiments in 1989:  . Citing second, the radiation experiments done at Aushwitz (objective to mass sterilize unsuspecting prisoners), as the U.S. government sponsored radiation experiments on some of the most vulnerable members of our society, long after the verdicts for this crime was handed down at the Nuremberg Tribunal.  The freezing / hypothermia experiments were conducted on men to simulate the conditions suffered by many of the soldiers of the German armies on the Eastern Front. The objective of the researchers was to find the best medical response for the thousands of German soldiers who were freezing to death and those soldiers debilitated by the cold. The experiments were designed to find the most effective way of rewarming German aviators who were forced to parachute into the North Sea. The experiments were conducted primarily at Dachau, under the supervision of Dr. Weltz and his assistant, Dr. Sigmund Rascher. The results of Dr. Rascher’s freezing experiments were publicized at the 1942 medical conference entitled "Medical Problems Arising from Sea and Winter":. Dr. Weltz also spoke on the subject "Warming up after Freezing to the Danger Point."  . The freezing experiments were divided into two parts. First, to establish how long it would take to lower the body temperature to the point of death, and second how to best resuscitate the frozen victim. The subjects of these experiments were young healthy Jews or Russian prisoners of war. The two main methods used to freeze the victim were to put the person in an icy vat of water (the fastest way to drop the body temperature) for up to eight hours at a time, or to put the victim outside naked, strapped to a stretcher, in sub-zero temperatures for 9 to 14 hours, as the victims screamed with pain as their bodies froze. The resuscitation or warming experiments by various means were equally as cruel and painful to the subjects as the freezing experiments, and resulted in horrible deaths:  . The results, or “data” from these experiments has raised serious medical ethical issues today. Is it ever appropriate to use data as morally repugnant as that, which was extracted from victims of the Nazi medical experiments conducted in the concentration camps? Simply put, is it ethical to use data gathered unethically? And if we're faced with this kind of situation again, how are we to respond? Furthermore, are there any circumstances where using such data is ethically permissible? It was these questions that brought together approximately 200 scholars for a conference in Minnesota in 1989:  . Behind the discussions was the fear that without ethical guidelines there could be future scientific abuses like those committed under the Nazi regime. The participants spent much of their time debating how the data from the Nazi experiments should be used, if at all.  The Use of Medical Data  The results of those studies have been available to medical researchers since the end of World War II. But in recent years several scientists who have sought to use the Nazi research have stimulated public controversy by raising the issue of social responsibility and potential abuses of science. It was not until Dr. Robert Pozos, a researcher on hypothermia, raised the ethical issue of whether he should utilize Nazi data collected on hypothermia, was there so much public attention drawn to this issue. Pozos’ research focused on the methods of rewarming frozen victims of cold. Pozos had to speculate what the effects would be on a human being at freezing temperatures. The only ones that put humans through extensive hypothermia research were the Nazis:  . Pozos had simply been the first scientist to raise the question publicly whether all this was ethically acceptable. However, he was hardly the first to use Nazi research data. The Journal of the American Medical Association (JAMA) published an article  (July 1946) by Dr. Molnar, a University of Rochester physiologist, who expressed no sense of any ethical ambiguity while writing about hypothermia survival based on Nazi data. In 1983, John S. Hayward at the University of Victoria used the Nazi hypothermia data to test survival suits carried in fishing boats in the freezing Canadian Arctic:  . According to the Hastings Center Report, there were at least 45 research articles published since the end of World War II that cited data from Nazi experiments:  .  The bioethical conference, initiated by Dr. Pozos’ questions was never satisfactorily resolved. "Ethicists never answer a question," Pozos said. "They raise one question, which raises another question and another. I want guidelines. I want to know if the data is good, should we use it? Or should the data forever be banned?"  . A significant number of scholars who attended felt that they should apply a moral judgment, but let the data be used.  ''The question is not whether we should use the data, but how,'' said Dr. Robert Proctor, chair of the Science, Technology and Power at …