UK military nurses’ experience of ethical decision-making on deployment: a reflexive thematic analysis.

Brockie, Alan Fleming ORCID: 0000-0002-9681-6383 (2025). UK military nurses’ experience of ethical decision-making on deployment: a reflexive thematic analysis. University of Birmingham. Ph.D.

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Abstract

Background:

Military nurses are frequently exposed to complex, dangerous situations and trauma on a scale their civilian colleagues are unlikely to ever experience. Additionally, the role of the military nurse on operations is constantly redeveloping due to advances in healthcare, education, and responsibility as well as the changing character of conflict and deployment profiles. The unfamiliar situations and complex environments encountered in evolving combat and humanitarian operations, combined with advances in practice, means that deployed military nurses are increasingly likely to become more involved in, or lead, ethical decision-making (EDM) in military treatment facilities. The researcher conducted a PhD study which aimed to explore how military nurses experienced EDM, with the research question “How do UK military nurses experience ethical decision-making on combat and humanitarian deployments?” This was in a bid to determine how best to practically prepare this unique professional group for the future deployed ethical landscape.

Methods:

This qualitative study analysed the narratives of 30 semi-structured interviews with serving and retired miliary nurses, whose experiences spanned a period from the 1950s to the 2020s. A Reflexive Thematic Analysis of the data was undertaken according to the principles of Braun and Clarke. Line-by-line analysis immersed the researcher in the data, and codes were openly generated as analysis progressed. The coding and theme development constantly evolved throughout the analysis to ensure they remained true to the data, prioritised participants’ voices, and maintained academic rigour. Two broad themes, the first with a sub-theme, were developed.

Findings:

The first theme is: ‘Doing the right thing’, with a sub-theme relating to the utility of written codes and guidelines as a handrail to ethical nursing practice. The second theme is: ‘The deployed context influences the EDM of military nurses’. The study demonstrated that military nurses felt very strongly about the importance of quality EDM and ‘doing the right thing’, even if they could not always be as involved in the process as they would have liked. Opinion was divided as to whose responsibility it is to make ethical decisions in both the military and healthcare professional contexts, reporting hierarchy as a monolithic barrier in many cases. Participants felt that in the deployed military space, EDM is inevitably messier and more complex than in their ‘firm base' practice in the NHS. This is due to additional complicating ethical factors such as issues of dual loyalty conflict, scarce resource allocation, two-tiered care, impartiality, and interoperability with international colleagues. Military nurses regarded the good character expected of a nurse, a solid ‘moral architecture’ (including a healthy dose of moral courage), and their identity as military nurses (which was sometimes confused) as the cornerstones of ethical practice, and which governed their internal ‘moral compass’. There was also varying reliance on written codes and guidelines as an ethical handrail, from something to slavishly adhere to, to something to ignore in favour of their own judgment.

Conclusions:

To the best of the researcher’s knowledge, this is the first empirical study examining UK military nurses’ understanding and experience of EDM across a wide chronological and operational range. The deployed context influences the EDM of military nurses who are constrained from adhering to peacetime ethical principles, which international legal and ethical frameworks tell them they should, by the “big and decisive hammer” of military necessity (Gross and Carrick, 2013, p.5). There is confusion amongst participants in resolving the duality of their professional roles as nurse and serviceperson, which should be distinct, but pragmatically cannot. Some also appear to believe that they exhibit a higher level of moral sensitivity than their doctor colleagues, making them indispensable in the collegial EDM process. Pre-deployment training has been identified as the weak link in preparing military nurses to experience deployed EDM, and ethics education in the Defence Medical Services needs to be ‘front-loaded’ to rectify this. Use of the MOD’s Four Quadrant Approach as an EDM tool, in combination with case-based learning rooted in real-world experience, has been identified as the optimal method of achieving this.

Type of Work:

Thesis (Doctorates > Ph.D.)

Award Type:

Doctorates > Ph.D.

Supervisor(s):