Journal of Clinical Nursing

ORIGINAL ARTICLE

Patient experience in the emergency department: inconsistencies in the
ethic and duty of care
Cheryle Moss, Katherine Nelson, Margaret Connor, Cynthia Wensley, Eileen McKinlay and
Amohia Boulton

Aims and objectives. To understand how people who present on multiple
occasions to the emergency department experience their health professionals’
moral comportment (ethic of care and duty of care); and to understand the
consequences of this for ‘people who present on multiple occasions’ ongoing
choices in care.
Background. People (n = 34) with chronic illness who had multiple presentations
were interviewed about the role that emergency departments played within their
lives and health–illness journey. Unprompted, all participants shared views about
the appropriateness or inappropriateness of the care they received from the health
professionals in the emergency departments they had attended. These responses
raised the imperative for specific analysis of the data regarding the need for and
experience of an ethic of care.
Design. Qualitative description of interview data (stage 3 of a multimethod
study).
Methods. The methods included further analysis of existing interviews, exploration of relevant literature, use of Tronto’s ethic of care as a theoretical framework
for analysis, thematic analysis of people who present on multiple occasions’ texts
and explication of health professionals’ moral positions in relation to present on
multiple occasions’ experiences.
Results. Four moral comportment positions attributed by the people who present
on multiple occasions to the health professionals in emergency department were
identified: ‘sustained and enmeshed ethic and duty of care’, ‘consistent duty of
care’, ‘interrupted or mixed duty and ethic of care’, and ‘care in breach of both
the ethic and duty of care’.
Conclusions. People who present on multiple occasions are an important group
of consumers who attend the emergency department. Tronto’s phases/moral elements in an ethic of care are useful as a framework for coding qualitative texts.

What does this paper contribute
to the wider global clinical
community?

• Insights into the impact of varia-

•
•

tion in health professionals’
moral comportment on healthcare consumers, particularly people with chronic illness who have
multiple presentations to the
emergency department.
Categorisation of four modes of
moral comportment concerning
the duty and ethic of care.
A method for achieving a further
and focused analysis of extant
qualitative data to achieve new
inferences and insights about
attributed practices.

Authors: Cheryle Moss, PhD, RN, Associate Professor, Faculty of
Medicine, Nursing & Health Sciences, School of Nursing and
Midwifery, Monash University, Clayton, Vic., Australia; Katherine
Nelson, PhD, RN, Senior Lecturer, Graduate School of Nursing,
Midwifery & Health, Victoria University of Wellington, Wellington, New Zealand; Margaret Connor, PhD, RN, Research Fellow,
Graduate School of Nursing, Midwifery & Health, Victoria University of Wellington, Wellington; Cynthia Wensley, MHSc, RN,
Research Assistant, Graduate School of Nursing, Midwifery &
Health, Victoria University of Wellington, Wellington; Eileen McK-

inlay, MA, RN, Senior Lecturer, Primary Health Care & General
Practice Department, University of Otago Wellington, Wellington,
New Zealand; Amohia Boulton, PhD, Associate Director, Whakauae Research Services, Whanganui, New Zealand
Correspondence: Cheryle Moss, Associate Professor, Faculty of
Medicine, Nursing and Health Sciences, School of Nursing and
Midwifery, Monash University, Clayton Campus, Building 13C,
Room C1.80, Clayton, Vic. 3800, Australia. Telephone:
+61 3 99053469.
E-mail: [email protected]

© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288, doi: 10.1111/jocn.12612

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C Moss et al.

Investigation into the bases, outcomes and contextual circumstances that stimulate the different modes of moral comportment is needed.
Relevance to clinical practice. Findings carry implications for emergency department care of people who present on multiple occasions and for emergency department health professionals to increase awareness of their moral comportment in care.

Key words: chronic illness, duty of care, emergency department, ethical framework, ethic of care, frequent attendance, health professionals, moral comportment, patient experience, usage
Accepted for publication: 15 March 2014

The experiences of consumers in respect of the care that they
receive from health professionals are important for feedback
and as precursors to development of services. In this study,
we report the findings from a qualitative descriptive stage of
a New Zealand (NZ)-based multimethod study, in which
people who presented on multiple occasions (PMPs) to the
emergency department (ED) were interviewed about their
usage of EDs. For these PMPs, the quality of care that they
received in the ED was important. The PMPs’ narratives were
analysed for what they revealed about health professionals’
moral comportment (the duty and ethic of care) from their
perspective as service users. Tronto’s (1993, 1998) ethic of
care framework was used to assist thematic analysis.

staff were on occasions ‘almost “like family”’, and on other
occasions, PMPs could experience being ignored or confronted by clinicians. The latter experience often created barriers to trust. The patients in Olsson and Hansagi’s (2001)
study talked about the importance of ED in their health care,
the positive contribution the ED can make and also their distress when their decision to present to the ED was not
respected by clinicians. These and other studies raise the significant impact on PMPs when they either do or do not have
a positive experience on presentation. Data collected in this
study generated the hunch that this impact is influenced by
the moral comportment (through the duty and ethic of care)
of the health professionals. Given the increased demand on
EDs and the focus on PMPs, gaining some insight into PMPs
experience of duty and ethic of care is important.

Background

The duty and ethic of care

The issue of people making multiple presentations to the ED
was initially raised in 1980s and is now recognised as an
international phenomenon (Nelson et al. 2011). As yet, there
is no agreement about how many presentations a person
needs to make to be defined as a PMP, but most researchers
use the definition of four or more presentations a year. Concern from health professionals about PMPs arises because of
PMPs’ high resource use and vulnerabilities and the difficulties they as clinicians have in addressing PMPs’ health.
Although some interventions to reduce the need for PMPs to
regularly present to the ED are now being found to be effective, multiple presentation is expected to be an ongoing issue
(LaCalle & Rabin 2010, Althaus et al. 2011). Therefore,
knowing about PMPs’ experiences is important.
The few studies that have involved interviewing PMPs
about the ED have revealed that the PMPs have experiences
of care which are variable. Malone’s (1996) early and still
significant work found that PMPs’ relationships with ED

The duty of care in nursing and in health care has long
been recognised in law and in professional ethics. Fullbrook
(2007) reminds nurses and health professionals that ‘the
overarching legal perspective that informs practice is the
principle of the duty of care’, that this principle is linked to
a ‘legal duty not to cause harm to those who rely on our
declarations of professional competence’ and that these are
‘woven into all other debates and reflections of our legal
duties’ (p. 17).
Codes of ethics written for health professionals have duty
of care/duty to care as an inherent principle (Schroeter
2008, Pfrimmer 2009). Duty of care involves the health
professionals’ primary commitment to the well-being and
care of the patient (American Nurses Association 2001).
Debates regarding the ethical assessment of balancing duty
to self and duty of care usually weight the existential, social
and health vulnerabilities of the health professional against
those of the patient. Where risk is on the patient’s side, the

Introduction

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Journal of Clinical Nursing, 24, 275–288

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moral imperative to enact in favour of the duty of care is
evoked (Rogers 2002, Joint Centre for Bioethics Pandemic
Ethics Working Group 2006, Fullbrook 2007, Schroeter
2008, Pfrimmer 2009). The duty of care is recognised as a
baseline of professional intervention and involves the exercise of moral and professional responsibility and judgement.
The ethic of care is a higher-order moral and practical
expression of care than duty of care.
Classically, the ethic of care in nursing is one expression
of virtue ethics (Brody 1988, Fry 1988). It is based on the
moral imperative of caring that requires the health professional to be person-centred in decision-making and professional judgements (Benner & Wrubel 1989, Fry 1989,
Watson 1990, Liaschenko 1993, Benner et al. 1996).
Within nursing, the ethic of care is acknowledged as a central component of health professional–patient relationships
(Gadow 1980, Benner et al. 1996, Swanson 1999, Austin
2007, Rundqvist et al. 2011) and of achieving cultural
safety within these (Duke et al. 2009, McEldowney & Connor 2011, Brannelly et al. 2013). The provision of the ethic
of care in practice is context-laden and sensitive to the
complexity of situations (Benner et al. 1996, Rodney et al.
2002, Peter & Liaschenko 2004, Barnes & Brannelly 2008,
Schluter et al. 2008, Hartrick Doane et al. 2009, Laabs
2011). Practising an ethic of care is evident in the everyday
approaches used by health professionals and embodies values of respecting the dignity, humanity, differences and
expertise of persons, being nonjudgemental and wherever
possible empowering transformation, self-efficacy and selfcare (Swanson 1999, Rundqvist et al. 2011). Advocating
the best interests of the patient as expressed by the patient
is inherent in this approach (Bishop & Scudder 1985,
Swanson 1999, Storch et al. 2009). Responding to the
needs of consumers with an ethic of care is complex (Benner et al. 1996, Barnes & Brannelly 2008). Nurses interested in the challenges of everyday practice recognise that
the greater the issues (number, significance) present in the
caring relationship, the greater the need for practical moral
reasoning and comportment (Benner et al. 1999, Rodney
et al. 2002, Dierckx de Casterle et al. 2008).
Given the limited ED literature on PMPs that specifically
addressed the importance of health professional moral comportment and the ethic of care in services, theoretical
sources to help frame relevant concepts and processes were
sought. After reviewing several frameworks including
Bishop and Scudder (1985), Fry (1988) and Benner et al.
(1996), we selected Tronto’s framework on an ethic of care
to understand PMPs’ experiences of duty and ethic of care.
Tronto, a political philosopher and feminist, was chosen
because her framework contained concepts that resonated
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

Ethic and duty of care in the emergency department

with raw data that were already collected (in relation to
caring about, caring for, care giving and care receiving).
Tronto’s framework was used (Barnes & Brannelly 2008)
in other health research to understand what people do and
the meanings that are attached to their practices.

Tronto’s ethic of care
Tronto’s (1993, 1998) ethic of care framework (Table 1)
has four inter-related phases, each underpinned by a moral
element: ‘caring about and attentiveness’, ‘caring for and
responsibility’, ‘care giving and competence’ and ‘care
receiving and responsiveness’.
Tronto’s ethic of care was philosophically congruent with
the research intent. Her view of the ethic of care involves genuine engagement, feedback and responsiveness from those
receiving care, especially where vulnerability and power
imbalances exist. In addition, we were mindful that Sevenhuijsen (1998) had adapted Tronto’s phases of care and
added the moral element of trust. Barnes and Brannelly
(2008) had also identified that trust is critical to effective
competence and that the emergence of mistrust from either
or both parties will interfere in the achievement of an efficacious outcome. This expanded view of what it means to be
moral in everyday practice enabled the analysis to be focused
and health professional moral comportment (duty and ethic
of care) to be directly attributed from the PMPs’ narratives.

Methods
Overall study design
In this study, the stage 3 results of a multimethod, multistaged descriptive study about the place of ED within lives
of PMPs are reported. The ethically approved study was
conducted in NZ between 2010–2012. The study consisted
of five stages (Table 2). Originally, only two stages were
designed. The richness of the descriptive textual data
obtained during stage 2 resulted in further focused analyses
being undertaken (iterative and reflexive responses) in
stages 3, 4 and 5.

Stage 3 design
The initial qualitative analysis during stage 2 of the
research revealed powerful insights into the PMPs’ perspectives and needs for care in the ED. The PMPs had been
recruited from three EDs across NZ (two urban and one
provincial public hospitals). Participants were purposively
recruited for demographic and clinical variation. To be

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C Moss et al.
Table 1 Tronto’s phases and moral elements in an ethic of care
Phase and moral
element
Caring about and
attentiveness
Caring for and
responsibility
Care giving and
competence
Care receiving and
responsiveness

Description
Attending to a person through listening attentively to their verbal and nonverbal expression of need and
making judgments about what approach will be most efficacious in meeting these needs. Attentiveness takes
account of the situation of the carer in relation to the person being cared for.
Taking responsibility for meeting the need/s identified whether it is within direct interventions or more
indirectly through the organisation of appropriate and competent people who are in a position to meet the
need. Responsibility by someone and/or some service is taken to set in motion what is needed.
Providing the competence needed to ensure that the best therapeutic intervention is given whether from one
person or service or from multiple people or services. Contextual influences such as inadequate resources or
inadequate preparation of the carer or carer indisposition can affect the outcome of caregiving.
The response of the person in need of care in relation to their interpretation of the care given and the extent
such care met the identified need. For recipients, it is their perception of the ‘goodness’ and ‘efficaciousness’
of care they receive. It requires that a response of some sort, verbal or nonverbal, is made by the person,
family or group receiving care. Responsiveness is a critical element in the moral imperative of involving
those cared for to share their perceptions of the service received and the burden they carry that has been the
impetus for seeking care. It is an assessment of the degree to which the unmet need is met in a competent
way and what other need might be revealed. Responsiveness provides material feedback for another cycle of
attentiveness, responsibility, competence and responsiveness.

Table 2 Study design
Study stage, aim and methodology

Data collection and analysis

Stage 1: Descriptive quantitative study
Aim: To study the presentation patterns of people
with chronic illness who had multiple
presentations (PMPs) over 12 months to New
Zealand (NZ) emergency departments (EDs)
Stage 2: Descriptive qualitative study
Aim: To understand from PMPs’ accounts when
and why they went to the ED and how that fitted
with their lives and health care
Stage 3: Descriptive qualitative study – iterative
response to stage 2
Aim: To understand from PMPs’ accounts of their
ED care their attributions of health professional
comportment of the duty and ethic of care and to
understand the consequences of this for PMPs’
ongoing choices in care
Stage 4: Descriptive qualitative study – iterative
response to stage 2
Aims: To identify the significance of pain as a
concurrent symptom, for PMPs when they
presented to the ED. To understand PMPs’
perceptions and experiences of ED staff attitudes
towards their pain
Stage 5: Descriptive qualitative study – iterative
response to stage 2
Aim: To understand from PMPs’ accounts of their
ED usage the aspects of social conscience that
influence their health service choices and actions

Retrospective presentation and outcome data from all ED presentations (one year –
2009) were collected from three NZ EDs (two urban and one provincial). ED usage
data (n = 81,442) analysed to determine NZ PMP patterns (three statistical
approaches). Study population demographics analysed for similarities and
differences in presentation patterns.
Interviews with 34 PMPs (≥6 presentations/12 months) from the three EDs about the
role of ED in their health care. Recruitment criteria: last ED presentation for a
chronic respiratory or mental health issue. Thematic analysis to identify the factors,
trajectories and influences on ED usage.
The 34 interview texts were further analysed using Tronto’s ethic of care
(framework) and thematic analysis. Descriptive findings from PMPs’ texts to
identify patterns and importance of ED health professional enactment of a duty and
ethic of care to the PMPs.

The 34 interview texts were further analysed related to pain and pain management in
the ED. 18 of 34 texts contained accounts of pain.
Analysis of these 18 texts to identify themes in the PMPs’ experiences and their
perceptions of barriers and facilitators to optimal pain care in ED.

The 34 interview texts were further analysed for understandings and themes in
PMPs’ exercise of social conscience and moral responsibility particularly related to
ED usage.

included, people had presented to any of the EDs a minimum of six times over 12 months (the last presentation
was for either chronic respiratory or mental health reasons).

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A nurse from each ED reviewed the list of potential participants (obtained from routinely collected data) and then
telephoned to establish interest and consent to pass contact
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Original article

details onto the research team. People (34 of 37) consented
to participate and were interviewed on one occasion (45–
90 minutes, using semi-structured interviews with sufficient
open-endedness to encourage narratives of experience. The
interviews (31 in person, three by telephone) were planned
to cover a minimum of six areas in conversation with each
PMP: demographic and social context, when and why they
last attended the ED, health history and health services they
use, ED experiences – recent and past, what normally follows an ED presentation and how their overall health care
including their ED experience could be improved. During
the interview, without specific prompting, all 34 PMPs
shared views about the appropriateness of the care they
had received in the ED and many spoke how they as PMPs
had responded. The majority openly discussed their need
for safety and for being treated with dignity by the ED
staff.
The aim of stage 3 was to understand from PMPs’ accounts
of their ED care their attributions of health professional comportment of the duty and ethic of care and to understand the
consequences of this for PMPs’ ongoing choices in care.
Table 3 describes the research structure (design, methods and
outcomes) of stage 3. To further analyse the existing data, relevant and research-congruent concepts were needed. The outcomes from the search for these are reported in the
background. No further data were collected from the participants as there was sufficient information in the existing transcribed interview texts to undertake further analysis. Texts
were read and analysed as reported in Table 3. The codification process resulted in saturated themes: (1) four positions of
moral comportment of duty and ethic of care attributed to ED
health professionals and (2) description of the impacts of these
comportment positions on PMPs.

Results
The sample
The 34 PMPs were aged between 17–77 years; 68% were
female and 70% identified as being NZ Europeans; the
mean number of ED presentations over 12 months was 19
(range 6–50+).

The experience and needs of PMPs
The analysis of the 34 participants/transcripts yielded 46
scenarios as data. The PMPs usually named several chronic
health conditions and shared reports of events that impacted
on their health. Mainly they sought safety and sanctuary
from the ED and presented when their self-management
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

Ethic and duty of care in the emergency department

strategies were unable to stave this off. Also, they revealed
how previous presentations either decreased or increased
their vulnerability. Many PMPs kept copies of letters of
referral and discharge, and consultation summaries. PMPs
mainly came to ED with an expectation that they would
receive professional expert care and would have their dignity
respected. Their scenarios did not always reveal the achievement of this state.
Scenarios often demonstrated journeys through each ED
visit in which passage from arrival and assessment, treatment, leaving ED and post-ED care were clear. Other scenarios exhibited integration where PMPs consolidated their
multiple visits and provided overall thoughts as if offering
us a comprehensive insight into their journey through ED
and beyond. In the textual analysis, we examined the overall tenor of the narrative and the specific accounts of events
provided by the PMPs about their experiences and insights
into their care. The analysis led to four moral comportment
positions being identified (Table 4), each described in
the following sections with reference to PMPs’ experiences.

Sustained and enmeshed duty and ethic of care
Multiple scenarios (17
5% of the data) about situations
where the health professionals had seamlessly enmeshed the
duty of care and the ethic of care were shared by eight
PMPs. These were situations in which PMPs experienced
care that directly honoured their humanity and sustained
their dignity, while receiving what they believed to be highly
appropriate and competent treatment and management.
The seamlessness occurred either between treating health
professionals or in the care the PMPs received from when
they presented until they were discharged. For instance,
whether the PMP was known to the health professional, or
not, being greeted warmly by the triage nurse when
assessed their urgency was a positive person-centred start to
their experience. The verbal/nonverbal communication of
such a greeting acknowledged their humanness and vulnerability, which supported PMPs’ decision to come to ED as
‘right’ for their predicament. Treatment when it came went
smoothly with the PMPs experiencing an acknowledgement
of their expertise and an honouring of what worked for
them. The scenarios reveal that when a consistent ethic of
care was experienced, the PMPs left the ED knowing what
was now required and they were linked back into community services that supported them. For example, Ursula
(Vignette 1) reveals her attribution of sustained and
enmeshed duty and ethic of care that she generally receives
from health professionals in the ED.

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280
Design, methods and outcomes

Research question: What did people who present on multiple occasions (PMPs) reveal about their experience of ethic and duty of care in emergency department (ED)?
Aims:
1 To understand from PMPs’ accounts of their ED care their attributions of health professional comportment of the duty and ethic of care.
2 To understand the consequences of this (1) for PMPs ongoing choices in care.
Subsequent literature review
A new literature search to locate literature related to patient experiences in ED and the duty and ethic
of care from patients’ perspectives, to inform the focus of the data analysis.
Ethic of care framework
Selection of Tronto’s (1993, 1998) moral elements in an ethic of care with the addition of trust as a
framework for iterative and reflexive analysis.
Recodification and interpretive reading of the existing interview
Two researchers independently read and coded the transcripts.
texts (n = 34) to gain understanding of the meanings intended by
First reading and thematic analysis: Moral content in the transcripts in relation to expectations and
the PMPs, and consideration of how the content and themes
experiences regarding the duty and ethic of care.
descriptively revealed the importance of a duty and ethic of care to
Second reading and thematic analysis: Moral content as it related to Tronto’s moral elements: Caring
them
about and attentiveness, caring for and responsibility, care giving and competence, care receiving and
responsiveness. Also read looking to understand the connection to trust
Third reading and thematic analysis, combined with themes and content derived from first and
second reading of the texts. Themed in relation to four moral comportment positions: sustained and
enmeshed duty and ethic of care, consistent duty of care, interrupted or mixed ethic of care and care
in breach of both duty to care and ethic of care
Researchers identified themes and emergent categories for moral comportment positions, and general
saturation of the categories and fit of these with the majority of the data.
Explication of health professionals’ moral positions as they were
The four moral comportment positions were documented and reported in two ways. All related
reflected through the PMPs’ experiences
sections in each of the 34 transcripts were referenced by transcript number and line numbers, and
exemplars were named against the moral comportment positions. This enabled each moral position
to be fully described in relation to the referent data. Each transcript was cross-referenced in relation
to the moral comportment positions that were present. This enabled each PMP’s experience to be
studied for consolidated or variable experiences of the ethic and duty of care from the health
professionals.
Validity and limitations
Confirmability: Reflexive and iterative approach, use of literature/ethic of care framework for focussed
analysis, three levels of transcript reading/coding for saturation and triangulation.
Dependability: Detailed audit trail kept as highlighted above
Authenticity: Realities of PMPs’ experiences and impact of ED health professional duty of ethic and
care demonstrated and synthesised.
Credibility: All data reported. The transcripts used had been confirmed by the participants (second
stage). Third-stage analysis and findings were not cross-checked with the participants.
Transferability: Context of data collection and analysis reported.
Findings limited: Further analysis of interview data as the original interviews did not directly seek
information from PMPs about the moral comportment of ED health professionals in relation to the
duty and ethic of care.

Steps in stage 3

Table 3 Stage 3 methods and research structure

C Moss et al.

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Ethic and duty of care in the emergency department

Table 4 Four moral comportment positions attributed to emergency department (ED) health professionals
Moral comportment position

General description

Sustained and enmeshed
duty and ethic of care

Situations where the duty of care and the ethic of care are enmeshed together seamlessly. People who
present on multiple occasions (PMPs) encountered an approach that always honoured their humanity
and respected their dignity together with receiving appropriate and competent care
Situations where good competent instrumental and efficient care were achieved to stabilise their
situation from a seriously life-threatening state. The PMPs’ level of consciousness was sometimes
such that there was no recall of any specific person-centredness connection with the health
professionals
Situations where positive and negative experiences of care were both encountered. In this category, PMPs
mostly acknowledged they received a combination of appropriate, efficient professional care, and
depending on the personnel present, they either felt welcomed and well supported or not welcome or
appropriate as a patient because their predicament was not seen as worthy of emergency care
Situations where the PMPs did not receive appropriate care or intervention, or they were not
consulted about or involved in decision-making about them, and they sensed an assault to their
dignity and humanity

Consistent duty of care

Interrupted or mixed ethic of
care

Care in breach of both the
duty to care and ethic of care

Vignette 1 Sustained and enmeshed duty and ethic of care – Ursula
Ursula, a middle-aged woman with psychiatric diagnoses and selfharming tendencies, had a safety care plan, steps of which determined whether she attended the ED or sought other forms of treatment and support. When Ursula attends ED, she usually finds the
ED team are respectful of her choices and judgements in relation
to the plan. Says Ursula ‘I’m well-looked after they stitch up my
cuts, and they’re always very nonjudgmental and accepting of me
being at ED’ (L88–90) and ‘[people] treated me really respectfully
and asked me appropriate questions’ and ‘they have certainly got
a standard of treatment that is really good for myself’ (L104–107).
Treatment, the length of time spent and destination from ED
(home or admission) ‘varies in relation to how I am physically and
mentally and according to the care plan’ (L129–154). Summing
up her experience of using the ED for care Ursula says. The system
that they have in place in the hospital works really well, they see
me as a person, rather than a patient, they know me . . . they put in
place what it is my need is, and do that promptly and in a timely
way. I’ve got experts. That’s what I’ve experienced (L681–687).

The attribution of these characteristics of care was similar across scenarios. For Ursula and the other PMPs,
Tronto’s phases of attentiveness, responsibility and competence were shared, sustained and chained by health
professionals involved in the care. Together, these health
professionals achieved highly effective technical care and
interventions while engaging in dignity-building interpersonal processes with the PMPs. The moral comportment
of the professionals complemented each other to the
extent that Ursula and the other PMPs responded with
satisfaction, gratitude and confidence with what they
perceived as a seamless, competent and exemplary care
delivery.

© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

Consistent duty of care
Scenarios (37% of the data) about consistent duty of care
by the ED staff were shared by 16 PMPs. Scenarios,
which were classified into this category, typically revealed
situations where the PMPs received technically specific,
competent and efficient care, which was aimed at assessing, treating and/or stabilising their situation. Several
PMPs experienced serious life-threatening states, and their
recall was often limited about the situation and interventions that they received. Other PMPs with less life-threatening situations recalled the efficiency of the care, but
had no recall of any specific person-centred connection
with the health professionals. Julia’s vignette (Vignette 2)
was selected because it contained examples of both situations.
Julia’s experience enables her to trust the professionals to
assess her needs and to respond appropriately. Experience
enables Julia to work with the ED team, and their precision
as a clinical team enables them to be responsive to her state
of illness and to initiate the correct level of intervention
and risk management.
The ED health professionals are efficacious, attentive to
changing need, take responsibility for the sophisticated
technical care needed for Julia to live and give that care.
Julia’s responsiveness is heard in the gratitude and confidence she attributes to ED. Julia trusts the ED to pursue a duty to care and do all in its power to aid her
survival of an attack. The professionals trust that Julia
knew when the time was right to handover her care to
them.

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C Moss et al.

Vignette 2 Consistent duty of care – Julia
Julia, a 60-year-old woman with chronic emphysema, had been
to the ED on five occasions over the previous five months. Julia
shared that she has a good routine to manage her chronic breathing problems and that the ED manage her well when she presents
there for care. She says ‘They’re very good, they usually start the
intravenous antibiotics straightaway, and they up the prednisolone straightaway, and they’re onto it’ and ‘respiratory, I reckon
they’re pretty much onto it with me’ (L684–688). To create further emphasis Julia added ‘I’ve heard lots of bad things about
ED, everybody’s said lots of things about EDs, but I’ve never had
a real problem, because they’ve just been onto it’ (L721–723).
In addition to these ‘standard’ presentations, Julia shared two
scenarios about attending the ED for acute life-threatening problems. In both situations, she had attended her general practitioner
in the morning for what she perceived as a problem needing
assessment and treatment (visit 1: breathing difficulties, visit 2:
chest pain). On both occasions, her GP had assessed her,
explained her symptoms and sent her home; Julia then found that
her situation deteriorated and she needed to be taken by ambulance to ED. On the first occasion, she had developed pneumonia
and needed admission to ICU; on the second occasion, she had a
myocardial infarction and needed acute treatment and admission
to CCU. Julia spoke of how with her acute situation she could
recognise the professionalism of the assessment and the rapidness
with which the team could identify and respond to her acuteness.

The PMPs’ scenarios that exemplified consistent duty of
care all contain accounts of ‘technical smoothness’ and
competence. None of these PMPs experienced ‘any glitches’
in their care. It was notable that while these accounts were
devoid of statements about gaining respect and dignity from
the health professionals, neither did they identify any situations where respect and dignity were not preserved. This
suggests that during the expression of consistent duty of
care, respect and dignity are contained to the level of
‘ordinary’ – present but not remarkable.

Interrupted or mixed duty and ethic of care
Interactions with health professionals, which could best
be described as an interrupted or mixed duty and ethic
of care, were apparent in 19
5% of scenarios. The 10
PMPs who experienced mixed duty and ethic of care
responses had a mixed sense of satisfaction that left them
wondering how they will be received when seeking help
again.
Three characteristic patterns were associated with the
mixed duty and ethic of care. One pattern was when
PMPs encountered inconsistencies in duty of care or tech-

282

nical intervention when the health professionals were perceived to vary in practice from competent to incompetent
or inappropriate clinical care. Another pattern was when
individual staff or groups of staff had mixed attitudes to
the PMP (e.g. sometimes supportive and sometimes judgemental). A further pattern was when PMPs encountered
disconnections between the interpersonal skills and the
technical intervention skills of the health care team (e.g.
technically able but interpersonally inadequate or vice
versa).
In Vignette 3, Christine’s experiences reveal mixed and
interrupted duty and ethic of care. Christine is responsive
and knows that any treatment needs to take account of the
‘whole picture’ of her health circumstances and to give an
accurate picture of the adverse outcomes of treatment.
Given the trial-and-error approach to her medication and
treatments, her trust in the health system is minimal. Basic
instrumental attentiveness, responsibility and competence of
the health professionals are apparent in offering pharmaceutical treatment. The account of 13 previous presentations and 13 different medications is revealing of limited
health professional acknowledgement of ‘whole picture’
and the paradoxes inherent in different prescriptions and
the overwhelming nature of Christine’s physical and existential pain.
This is contrasted by the attempt of the ED nurse to
acknowledge and respond to these issues and to achieve
streamlining and coordination of Christine’s care. While
these actions resulted in new assessments from health
professionals, their arguments in front of Christine and
her husband were illustrative of inadequate interpersonal
skills and care strategy resolution. Christine’s discharge
without a care plan and agreed follow-up reveals a futile
end position as outcome of the nurse’s moral intent and
ethic of care. It also reveals the consequences when professional difference between clinicians fails to resolve and
results in their abdication of responsibility in relation to
a clear care plan. The narrative demonstrates a system
failure and showcases mixed duty and ethic of care.
Christine’s powerlessness and vulnerability is expressed
in her inability to ‘match up all the dots’ encountered in
her referrals and treatment from various services and
what appears to be the inability of her health professionals to provide holistic care. Health professionals working
cooperatively to connect the dots would be a positive
movement towards achieving the moral principles of
attentiveness, responsibility, competence, trust and
responsiveness within her care strategy.

© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

Original article

Vignette 3 Interrupted or mixed duty and ethic of care – Christine
Christine attends ED for the control of ‘severe pain, severe
migraine’ (L245) and for suicide attempts related to the frustration of the pain and associated medication side effects. Christine
endeavours to live as normal a life as possible and seeks help when
her self-care is inadequate. Christine’s experience of medication is
reported as ‘every doctor I see [in ED] used to prescribe different
medications so we just go on this merry-go-round of more medication’ (L303–304).
Christine had visited ED ‘13 times and been put on 13 different
medications’ (L54). That ‘we try to put our hands up every time
we go to A and E but usually I am too ill and crook, my husband
tries to say something, but I just get pretty drugged up, put onto an
intravenous combination, wheeled into short stay and then left to
go home’ (L184–187). She summed her condition up as ‘all I know
is that I’m far from well and in a lot of pain and I’ve taken all the
medication, I don’t know what else to do’ (L299–300). This has
made her ‘terrified’ of going to ED because ‘I’d be put on another
drug that makes me sick’ (L344). Christine believes that her health
problems are not taken seriously and that the health professionals do
not ‘step back and look at the whole picture and what is going on’
(L81). The pain clinic had promised help and failed to follow through,
but eventually saw her after suicide attempts and accidental overdoses.
Christine told of a recent episode of ‘severe pain down my neck and
arm – all through the day, all through the night’ (L231–232). The nurse
had been reassuring to Christine on her arrival to ED for management
of the problem. The nurse had said ‘look you are in trouble, you’re in
the right place’ (L261–262). The same ED nurse organised for Christine
to be assessed by the Pain Clinic and the Crisis Assessment Team (CAT)
while she was in the ED. Christine reported that the two teams argued
in front of her and her husband ‘the pain team said I need to get the
depression addressed’ (L285) and the CAT team said ‘you need to get
your migraines fixed’ (L288). Says Christine ‘I just burst into tears and
said I can’t connect up all the dots, I can’t connect you all up’ (L291–
292). On discharge from ED, there was no follow-up care provided.

Care in breach of both duty of care and ethic of care
Scenarios (26% of the data) in which PMPs encountered an overall sense of breaches in both duty of care and ethic of care by the
professionals were shared by six PMPs. Examples in this group
included participants who were barred from returning to ED
(except for situations where they had been assessed as critically
ill) because their recurrent presentations had been assessed by
ED staff as not appropriate. Two PMPs shared accounts of being
in the ED needing to use toilet facilities or pans/urinals and being
told to soil themselves (defecating) without an explanation as to
why this was being asked of them.
In Vignette 4, Bernard and his wife who accompanied him
were grateful recipients of care and did all in their power to
learn the system and fit in with it. However, when this
‘ignominious’ situation arose, they felt utterly powerless and

© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

Ethic and duty of care in the emergency department

disappointed that the system they had mastered and trusted
had let them down. Rather than giving feedback to the health
professionals about this episode, their sense of power imbalance and need for compliance led them to the decision of
acceptance of health professional behaviour.
Vignette 4 Care in breach of both duty of care and ethic of care – Bernard
Bernard, an older adult living with emphysema, sought safety in ED
for an exacerbation of his condition when his breathing became
severely distressed. Bernard reported an ‘ignominious situation’
(L346) that was experienced as an affront to his human dignity. He
had a tendency to stress incontinence and he needed to move his
bowels while his treatment was stabilising his breathing. Bernard
requested assistance as he could not get to the toilet himself and was
told to soil himself where he was. On reflection, he believes he
should ‘be quiet and accept it and do what you’ve got to do’
(L352).

Examination of Bernard’s situation reveals there is health
professional attentiveness to him (duty and ethic of care),
inappropriate and inadequate hygiene advice (duty of care)
and no vehicle to ascertain the responsiveness of the patient
(duty and ethic of care). The combination of specific actions
taken by the health professional in the scenario resulted in
overall breaches of both the duty to care and ethic of care.
In Vignette 5, Allison sought help when self-management
strategies had become ineffectual. This reveals Allison’s compliance with her care plan, but her perceptions that she was
seen mainly as ‘drug seeker’ reveal her lack of trust in the professionals and their lack of trust of her. The judgement about
seeking drugs leading to a portrayal of Allison’s unworthiness
of care appears to be related to attitudes about her pain being
in her head and her repeated attempts to obtain help. These
moral positions were held and conveyed by the professionals
despite legitimate care planning and authentication of the pain
issues from other health professionals. Such judgements
breach the ethic of care and duty of care.
Allison and her mother attempted verbal feedback, made
ongoing representations of their situation, but their responsiveness met a wall of resistance. Such entrenched resistance, possibly promulgated between staff, demonstrated
further failure in a duty to care and an ethic of care. The
mother’s response that Allison’s complex condition was
beyond the scope of practice of the health professionals
reveals her explanation as to why the professionals systematically assaulted them (personal dignity and trustworthiness), and Allison received limited treatment as a
consequence.

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C Moss et al.

Vignette 5 Care in breach of both duty of care and ethic of care –
Allison
Allison attended ED for exacerbations of chronic pain related
to a multiple mix of chronic psychiatric and physical ailments.
Allison had a care plan for managing pain created by the pain
team. In keeping with the plan, she presented at ED for pain
management only after she had taken strategies to reduce her
pain and found them to be inadequate. She tried to avoid ED
because of the perceived attitude of the health professionals’
response ‘every time I go there is “Oh you’re here again, you’re
just a drug seeker”’ (L258–259). Allison reported an instance
of when she reminded a doctor of her pain plan, who in
response said ‘I’m not going to take any notice of it’ (L410–
411). Inferences are made that her pain is related to her mental
state and something that might be going on at home (L390–
391). Her mother who also attended the interview and is the
support person for Allison on many of the ED visits told of telling staff about the possibility of her pain being related to one
of her rare conditions where the perceived response was ‘we
don’t know about it, so it’s not happening’ (L487–488). When
her mother had tried to advocate for her daughter she had been
told that she ‘should be letting her do things for herself’ (L555–
556). Allison’s mother summed up her view by saying ‘I think
your (Allison’s) whole medical problems are too complicated
for them’ (L589).

Attributed moral comportment positions
In summary, the findings reveal that the PMPs experienced
and attributed four moral comportment positions with
respect to the care offered to them in the ED by the health
professionals (Table 4). No PMP encountered only ‘care in
breach of both duty of care and ethic of care’ across their
multiple presentations. All had at least some experience of
‘consistent duty of care’ or ‘an interrupted or mixed ethic
of care’. Some PMPs’ predominant experience was that of
either ‘sustained and enmeshed duty and ethic of care’ or
‘consistent duty of care’. The impacts of health professionals’ moral comportment (duty and ethic of care) on the
PMPs are identified in Table 5.

Discussion
Whose scenarios, whose experiences and what is the
legitimacy of these?
People who present on multiple occasions are an important
group of ED service users; they have chronic illness complexities and relative instabilities in their health status.
PMPs’ health journeys as well as their acute ED presenta-

284

tions need attention. The powerful thematic finding about
PMPs’ need for safety and being treated with dignity in the
ED generated targeted analysis about duty and ethic of
care. PMPs’ status as ED consumers needs to be heard and
their experiences of the moral comportment of ED health
professionals needs to be understood.
We acknowledge it is not ideal to research consumers’ experiences of health professionals’ moral comportment and to
attribute this to third parties who have no opportunities to
speak for and to their intentions and perspectives. Yet to have
these findings and not do justice to their further analysis
would have resulted in a form of consumer silencing. Little is
known about how PMPs attribute the duty and ethic of care of
their ED health professionals.
This study has limitations, as the findings result from one
cohort of PMPs who were recruited to share their perspectives on the wider topic of where the ED resides in their
lives and chronic illness health journeys. PMPs were not
asked specifically to comment on the moral comportment
of the health professionals in the ED. However, the emphasis that they gave to this enabled questions to be asked of
the data that had already been collected. The findings
reveal the merit of this work. There is need for further
research with PMPs and health professionals directly about
this.

Tronto as a theoretical tool for this research purpose
Tronto’s (1993, 1998) philosophic position regarding the
moral elements of attentiveness, responsibility, competence
and responsiveness linked to caring about, caring for, care
giving and care receiving within the ethic of care provided
a useful theoretical lens by which to understand and analyse the narratives provided by the PMPs. The additional
moral element of trust (Barnes & Brannelly 2008) was also
consistent with the morally embedded texts generated by
the PMPs’ interviews. The resultant modes of moral comportment attributed to ED health professionals working
with PMPs emerge directly from these philosophic bases
applied analytically to the PMPs’ texts. There is need for
more research and theorising of this type using Tronto’s
moral elements and phases of the ethic of care. This will
either advance the findings from this project or challenge
any idiosyncrasies in them.
Other theoretical frameworks may offer similar, competing or different findings. For instance, Naef (2006)
and Delmar (2008), respectively, offer comment about
choices we have in the process of human engagement (of
becoming involved) and that different people generate
degrees of easiness or difficulty for us in entering the

© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

Original article

Ethic and duty of care in the emergency department

Table 5 Impacts of health professionals’ moral comportment (duty and ethic of care) on people who present on multiple occasions (PMPs)
Impacts of health professionals’ moral comportment (duty and ethic of care) on the PMPs
When PMPs experienced ‘sustained and enmeshed ethic and duty of care’ as a morally comported position from health professionals, they
experienced:
• Seamless honouring of their humanity and lived experiences,
• Care that they believed was highly appropriate, competent and effective in managing the situation and in assisting their health transitions,
• Seamless chaining of interventions and intentions between health professionals to advance high-quality outcomes,
• Dignity enhancement,
• Confidence and trust in themselves and the services.
When PMPs experienced ‘consistent duty of care’, as a morally comported position from health professionals, they experienced:
• Efficiency of care,
• Highly skilled and smooth technical interventions,
• Chaining of interventions and intentions generally between health professionals to achieve effective care outcomes,
• No ‘glitches’ in their care,
• Gain in the trust they felt in the health professionals and the emergency department (ED) services to do their job.
When PMPs experienced ‘interrupted or mixed duty and ethic of care’ as a morally comported position from health professionals, they
experienced:
• Variations in care competencies,
• A mixed sense of satisfaction and powerlessness related to the hit and miss competencies in care,
• Intermittent or missed chaining of interventions and intentions between health professionals, varied intention and outcomes,
• A delicate state of trust in the health professionals and the ED services,
• Wondering about how they will be received when seeking help from the ED again.
When PMPs experienced ‘care in breach of both the ethic and duty of care’ as a morally comported position from health professionals, they
experienced:
• Affront, powerlessness and anger/fear or frustration with the services and/or the health professionals,
• A sense of entrapment in the vulnerabilities generated by their illness/es, and in the negative culture of care offered by the health professional/s in the health services,
• Incomplete resolution of the health issues and ineffective healthcare planning for post-ED care,
• Chaining of attitudes and intentions between health professionals which result in blocked care.

relational aspects of care. The findings of this research
need extension and challenge from other theoretical perspectives if they are to help consumers and health professionals to probe, reflect and modify their connections and
responses to each other as they occupy different positions
in their care roles.

Implications from the findings – the four moral
comportment positions
The findings generate important insights into and questions about PMPs’ experiences in the ED and the consistencies and inconsistencies that they encountered in the
duty and ethic of care by health professionals. Moral
comportment positions have been delineated and
described from the PMPs’ narratives. The comportment
positions add to understanding of PMPs’ needs and by
inference knowledge of the moral responses of health
professionals caring for PMPs. Overall, the PMPs gave
more scenarios that revealed the ED health professionals
as generally providing ‘sustained and enmeshed ethic and
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

duty of care’, or a ‘consistent duty of care’, and sometimes an ‘interrupted or mixed duty and ethic of care’.
Not only does this suggest that the professionals enacted
their duty of care, it also gives a broad indication of the
moral climate associated with the care of PMPs.
While all PMPs encountered one or more of the four
positions in the provision of their care, just over a quarter of the scenarios revealed care that was experienced as
breach of both duty and ethic of care. There needs to be
investigation into which PMP situations evoke these positions and how the context and moral climate of the ED
influences individuals and groups of health professionals
in their modes of moral comportment. Studies that
explore how health professionals balance choices between
duty to care and duty to self (individual or group) may
be useful to understand more about their moral comportment.
The name and description associated with each of the
positions involving the duty and ethic of care will assist
future codification of moral comportment, and these
could be useful as indices of moral climate within the

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C Moss et al.

contexts of care. The descriptive attributes associated
with each of the positions in relation to what the PMPs’
experienced and their holistic outcomes generate impetus
for pursuing more focused research involving PMPs and
those who care for them. Such understanding would help
frame revision and development in systems of care for
PMPs.
The findings have relevance for what Rodney et al.
(2006) identify as moral climates. Desire to develop a
strong moral climate is needed to achieve integrated moral
practice such as that typified by the ‘sustained and
enmeshed ethic and duty of care’. Implications arise from
the findings about how to investigate moral comportment
generally and in relation to the care of PMPs so that greater
consistency in the expression of a strong moral climate can
be achieved.
There is need for further research into the characteristic forms of moral comportment (the duty of care and
ethic of care) of professionals as they work with consumers who are dependent on their actions. There is need for
engagement with health professionals about the contextual factors that they experience in relation to their
moral agency and how they see that these can be understood, analysed and further developed.
The method achieved iterative analysis of extant qualitative data and generated new inferences and insights
regarding attributed moral practices. Further research is
needed to test the robustness and dynamics of the categorisation and to build further understanding of the experiences of PMPs in the ED regarding their needs for
health professionals to consistently comport duty and
their ethic of care.

from these experiences warrant further investigation. The
results infer practices and moral comportment positions
that inform health professionals both about how their
care is perceived and the care needs of PMPs. The findings have implications for assessment of the care given to
and received by PMPs.

Relevance to practice
The findings carry implications for health professionals to:
• Proffer their practices and awareness of their moral
comportment and its impact on PMPs in their care,
• Advance strategies that build the moral climate of care
for PMPs with their colleagues in their workplace contexts and
• Gather insights from consumers in relation to their
moral comportment.
The findings have implications for PMPs (1) to sustain
courage in their self-knowledge, (2) to trust in the efficacy
of care in the ED and (3) to share their insights about the
care that they receive.

Acknowledgements
The research team acknowledge the generosity of the participants in sharing with us their thoughts and perceptions about
their health experiences. Time for the research was provided
by our workplaces and is acknowledged by the authors. The
work of Margaret Pack and Alan Shaw (formerly of Victoria
University of Wellington) for contribution to early conceptions of the research is duly acknowledged.

Disclosure
Conclusion
People who present on multiple occasions with chronic
illness presenting to ED came with the expectations that
they would be treated efficiently by competent professionals who would respect their dignity, acknowledge their
knowledge of themselves and respond sensitively to their
vulnerability. The majority of PMPs experienced some
forms of this. However, they also experienced variation
in the ways in which health professionals comported the
duty of care and ethic of care. Some PMPs shared situations where they had encountered direct breach by health
professionals of their duty and ethic of care.
The four descriptive categories of moral comportment
by health professionals in relation to the duty and ethic
of care will be important areas to pursue investigation.
The different outcomes and experiences that PMPs had

286

The authors have confirmed that all authors meet the ICMJE criteria for authorship credit (www.icmje.org/ethical_1author.html), as follows: (1) substantial contributions
to conception and design, acquisition of data, or analysis
and interpretation of data; (2) drafting the article or
revising it critically for important intellectual content; and
(3) final approval of the version to be published.

Conflict of interest and source of funding
The authors declare that there is no conflict of interest.
This work was supported by a Strategy to Advance
Research Grant (STAR) RG08 006. Ethical approval for
the research was granted by the Multiregion Health &
Disability Ethics Committee New Zealand MEC/10/02/
018.
© 2014 John Wiley & Sons Ltd
Journal of Clinical Nursing, 24, 275–288

Original article

Ethic and duty of care in the emergency department

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