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AbstrAct
Individuals who have maladaptive patterns of
drinking alcohol fall into the category of vul-
nerable research participants for many reasons,
not the least of which includes the stigma of-
ten placed on individuals who abuse alcohol.
Vulnerable subgroups within the population
of people who abuse alcohol include women;
older adults; incarcerated, socioeconomically
disadvantaged, and mentally ill individuals; as
well as people from racial minorities. Thus, as
research participants, individuals who abuse
alcohol can be labeled a doubly vulnerable pop-
ulation. Belonging to more than one popula-
tion simultaneously can lead to a compromised
ability to protect one’s own interests or greater
susceptibility to harm related to participating in
research studies. Arguments against including
people who abuse alcohol as research partici-
pants will be presented, followed by the argu-
ment for including these individuals, which is
suggested as the more ethically sound of the
two points of view.
Priscilla Gage Gwyn, PhD, ArNP-bc, OcN; and Jessie M. colin,
PhD, rN
3. process. This is particularly im-
portant when the research partici-
pants are considered vulnerable.
An assumption made by many re-
searchers when discussing vulner-
able populations is that “certain
categories of people are presumed
to be more likely than others to
be misled, mistreated or otherwise
taken advantage of as participants
in research” (Levine et al., 2004, p.
44). The Council for International
Organizations of Medical Sciences
(CIOMS) defines vulnerable peo-
ple as “those who are relatively (or
absolutely) incapable of protect-
ing their own interests [because]
they may have insufficient power,
intelligence, education, resources,
strength, or other needed attri-
butes to protect their own inter-
ests” (Commentary on Guideline
13 section). In this article, we will
demonstrate that a population may
be doubly vulnerable because they
experience more than one of these
problems. Research with these in-
dividuals necessitates that extraor-
dinary care be taken to avoid tak-
ing advantage of or harming them
in any way.
Research is essential to advance
knowledge and science; however,
the drive for new knowledge must
4. not be allowed to take precedence
over the welfare of research partici-
pants (U.S. Department of Health
and Human Services, 2005). Be-
cause of these constraints, the
challenges related to studying
people addicted to alcohol pres-
ents ethical concerns that could
discourage any research at all. We
contend that the challenges inher-
ent in such research simply make
ethically conducted research more
challenging, not impossible, and
that people who abuse alcohol
should be afforded the same oppor-
tunities as people who do not abuse
alcohol in being able to participate
in research studies.
the POPulAtiON Of
iNDiviDuAls whO Abuse
AlcOhOl
Regardless of setting, nurses will
find themselves responsible for the
care of people who experience al-
cohol dependence, abuse, or addic-
tion. In the United States, alcohol
abuse is reported to be one of the
most prevalent addictive problems
in the nation, if not the number
one addictive disease experienced
by Americans (Compton, 2002).
Alcohol-related injuries and ill-
nesses contribute to a large per-
5. centage of patient hospitalizations;
some estimates for hospitalizations
related to alcoholism are as high as
one fifth of all admissions (Comp-
ton, 2002).
Because health care provid-
ers care for people with a broad
spectrum of maladaptive drinking
patterns, it is important to under-
stand that identification of alcohol
abuse or dependence is based on
behavioral indicators of addictive
disease, not on a set volume of
alcohol consumed or frequency of
consumption (Compton, 2002).
Compton (2002) defines alcohol
abuse as “harmful and recurrent
alcohol use despite social, occupa-
tional, or legal consequences” (p.
59); alcohol dependence includes the
additional criteria of “being unable
to cut down or control alcohol
use, being physically dependent
on alcohol, and being tolerant to
alcohol” (p. 59). In addition, the
Journal of Psychosocial nursing • Vol. 48, no. 2, 2010 39
fourth edition of the Diagnostic
and Statistical Manual of Mental
Disorders (American Psychiatric
Association, 1994) specified that if
a person experiences three or more
6. of the following seven criteria
within a 12-month period, he or
she meets the criteria for alcohol
dependence:
l Tolerance, defined as a need
for increased amounts of alcohol to
achieve the desired effect.
l Withdrawal symptoms or
drinking alcohol to avoid with-
drawal symptoms.
l Drinking alcohol in larger
amounts than intended.
l Unsuccessful attempts at
cutting down on alcohol use.
l Excessive time related to ob-
taining, using, and recovering from
alcohol use.
l Social, occupational, or
recreational activities curtailed or
ceased due to alcohol use.
l Continued use of alcohol,
despite negative psychological or
physical consequences.
Many people feel that alcohol-
ism is a weakness manifesting from
a “character flaw” and that people
who have maladaptive patterns
of drinking alcohol could drink
7. “in moderation” if they wanted to
control their alcohol consumption.
In the past several decades, a sig-
nificant body of both national and
international scientific research
has delineated that there are ge-
netic factors, in addition to envi-
ronmental factors, that increase a
person’s risk of both alcohol abuse
and dependence (Dick et al.,
2006; Edenberg & Foroud, 2006;
Williams & Lu, 2008). Research-
ers have found that up to 50% to
60% of the risk for developing al-
cohol abuse and dependence is ge-
netic (Prescott & Kendler, 1999).
Because health care providers’
personal beliefs about people who
have maladaptive patterns of
drinking alcohol continue to vary
widely, more research is needed
with this population.
vulNerAbility
Having outlined how preva-
lent consumers of alcohol are in
health care arenas, expanding
further what constitutes a vulner-
able population is important, as it
supports the viewpoint that many
individuals who abuse alcohol are
doubly vulnerable. Vulnerability is
a common human experience that
has taken on an expanded meaning
in the field of research. Vulnerable
8. populations are those who have a
greater predisposition or suscepti-
bility to harm than other individu-
als (Levine et al., 2004; Moore &
Miller, 1999; Rhodes, 2005; Rog-
ers, 2005). Other definitions of vul-
nerable populations include those
with diminished autonomy and de-
creased decision-making capacity,
although Quest and Marco (2003)
indicated that this definition is
evolving. Quest and Marco (2003)
have expanded their view of vul-
nerability to include six areas:
l Those with cognitive im-
pairment who cannot make ade-
quate decisions about participating
in research.
l Those who are institutional-
ized and are at risk for feeling they
must participate and do not have a
choice to participate in research.
l Those who are deferentially
vulnerable. This area also refers
to individuals who feel they must
participate and do not have a
choice to do so due to subtle co-
ercion; the difference from those
who are institutionalized is that
informal authority causes this
group to feel their choice to par-
ticipate is removed.
9. l Medically vulnerable indi-
viduals with acute or chronic ill-
nesses for which no satisfactory
standard of treatment exists.
l Economically vulnerable in-
dividuals.
l Socially vulnerable individ-
uals are those belonging to a group
that is undervalued, such as people
who are homeless or addicted to
substances.
It follows that individuals who
abuse alcohol could be categorized
as socially vulnerable. Simultane-
ously, while belonging to a group
that is socially vulnerable, indi-
viduals who abuse alcohol often
belong to other vulnerable groups
as well and, therefore, could be de-
scribed as doubly at risk for harm
than other individuals, or more
simply, doubly vulnerable.
ethicAl GuiDeliNes fOr
huMAN reseArch
Several professional organiza-
tions have published documents
that outline ethical research con-
ducted with human participants,
and many address additional efforts
11. may experience decreased ability
to make decisions, these individu-
als have an increased propensity
for having their rights violated.
The most common ethical breach-
es related to research are coercion,
therapeutic misconception, undue
influence, and manipulation lead-
ing to study enrollment.
Coercion is using the threat of
harm or force to “push” individuals
to enroll in a research study, over-
riding their right to choose not to
participate (Israel & Hay, 2006;
Rhodes, 2005; Rogers, 2005).
Therapeutic misconception is the be-
lief that the benefits of participat-
ing in a research study are greater
than they actually are (Steinke,
2004). Undue influence is exerted
when people in positions of power
or respect encourage individuals to
participate, even when enrolling in
the study may not be in the partici-
pant’s best interest (Rogers, 2005).
Finally, manipulation is deliberately
changing the environment or the
information to lead others to make
decisions they otherwise would not
have made (Israel & Hay, 2006;
Rogers, 2005).
Using these tactics in accumu-
lating research study participants
violates the ethical principles
12. of beneficence (doing good acts
and avoiding evil), nonmalefi-
cence (doing no harm), autonomy
(choosing for oneself), distributive
justice (benefits and burdens should
be shared equally by all people in
an identical manner regardless of
social status, race, religion, or other
grouping), and informed consent
(Israel & Hay, 2006; Quest &
Marco, 2003; Rhodes, 2005; Stein-
ke, 2004). Informed consent has
four essential parts: adequate and
truthful disclosure of information,
freedom of choice in participation,
comprehension of the information,
and adequate capacity for deci-
sion making (Israel & Hay, 2006;
Rhodes, 2005).
ArGuMeNt AGAiNst
cONDuctiNG reseArch
with iNDiviDuAls whO
Abuse AlcOhOl
The argument against research
with vulnerable populations re-
lates to ethical compromises that
can occur at different levels of the
research study. Issues with consent
might not be overcome by indi-
viduals who abuse alcohol; there-
fore, it could be unethical to enroll
this population in research studies,
meaning they should be excluded
13. for their own protection. Ethical
standards need to be upheld when
conducting studies of any kind so
the participants’ rights, whether or
not they are doubly vulnerable, are
not violated.
The first point to be made
against conducting research with
vulnerable or doubly vulnerable
populations is that their enroll-
ment will always cause problems
with upholding ethical standards
related to the four essential parts
of informed consent. Being edu-
cationally and economically dis-
advantaged may place individuals
who abuse alcohol at risk for being
unable to fully comprehend the
study protocol and the research
consent.
Second, individuals who
abuse alcohol may have an erro-
neous belief that they will expe-
rience benefits if they choose to
participate in a study (i.e., thera-
peutic misconception). It can be
argued that it would not be pos-
sible to eliminate the potential
for coercion or therapeutic mis-
conception and ensure adequate
comprehension and decision-
making capacity of people who
abuse alcohol. Thus, appropriate
14. safeguards that ensure informed
consent and maintain confiden-
tiality, as well as the participants’
dignity, may be difficult at best.
A third argument is that a
great number of individuals
who abuse alcohol are socio-
economically and education-
ally disadvantaged. This could
easily make them susceptible to
coercion to enroll in a research
study. Also, many of those who
abuse alcohol are doubly vul-
nerable, placing them at higher
risk for harm if unethical meth-
ods are used to boost study en-
rollment.
Finally, participants may erro-
neously believe they may receive
the medical care they need by
participating in the study. Allow-
ing this therapeutic misconcep-
tion among participants is a more
subtle form of manipulation. The
argument is that unless all indi-
viduals in the country have equal
access to care, research with vul-
nerable individuals (who do not
have equal access to medical care
due to socioeconomic barriers)
should not be conducted. The
drive for new knowledge should
not take precedence over partici-
pants’ welfare.
15. In discussing ethical issues
related to the research design
itself, deontology lends support
to a final argument for not con-
ducting research with people
who abuse alcohol. Deontology is
the ethical philosophy in which
individuals are treated as an
end themselves, not simply as a
means to an end (Israel & Hay,
2006). Many research trials col-
lect information that may not
directly benefit those enrolled in
a study but that could help indi-
viduals in the future. Consistent
with deontology, only research
directly benefiting individu-
als who abuse alcohol would be
ethically acceptable.
Journal of Psychosocial nursing • Vol. 48, no. 2, 2010 41
ArGuMeNt fOr
cONDuctiNG reseArch
with iNDiviDuAls whO
Abuse AlcOhOl
The first point to be made in
support of research with doubly
vulnerable individuals is guided by
justice-based ethics. The founda-
tion of justice-based ethics is that
benefits and burdens should be
16. distributed among all in ways that
are fair and just. When benefits or
burdens are distributed unequally,
there is a strong presumption that
this should be remedied. Under-
represented concerns and special
health care needs of vulnerable
groups may never be addressed
if research studies are not open
to them. To exclude them would
counter the belief that research is
essential to improve knowledge
and understanding and to advance
science; limited decision-making
ability should not prevent individ-
uals from participating in research
nor impede researchers’ ability to
gain new knowledge.
Not allowing doubly vulner-
able individuals to participate
in research could also create an
ethical dilemma (Steinke, 2004).
Moore and Miller (1999) argued
that “only when vulnerable groups
receive the appropriate research
attention can their care and qual-
ity of life be enhanced” (p. 1040).
Therefore, research should be con-
ducted with individuals who abuse
alcohol to afford them the same
attention and life-improving re-
search to which those who are not
vulnerable have access, as it is not
fair or just to exclude doubly vul-
17. nerable groups.
Further support for conduct-
ing research with this population
is related to a rights-based ethi-
cal approach, which stems from
the belief that all human beings
have rights and the ability to
choose freely what they do with
their lives. Ethical actions should
be those that best protect and
respect the moral rights of those
affected and promote individuals’
ability to choose freely (Rhodes,
2005). To say the population of
those who abuse alcohol can-
not make voluntary and non-
coerced decisions about whether
they would like to participate
in research is paternalistic and
a breach of rights-based ethics
(Rhodes, 2005). Rhodes (2005)
also stated that this paternalism
“denies people the opportunity
to evaluate the costs and benefits
of research participation in light
of their own priorities, their own
goals, and their own values” (p.
12). Rights-based ethics supports
the argument that the doubly
vulnerable population being dis-
cussed can and should be permit-
ted to evaluate for themselves and
freely choose whether they would
like to participate in research
studies and should have the same
18. rights as nonvulnerable popula-
tions and not be barred from tak-
ing part in research studies.
Support to conduct research
with people who have maladap-
tive patterns of drinking alcohol
is based on researchers’ ability to
minimize ethical breaches of the
four essential parts of informed con-
sent and their ability to institute
appropriate safeguards to protect
participants’ confidentiality and
dignity. Researchers must provide
adequate and truthful disclosure of
information at a level that allows
comprehension on the part of the
participant. The study’s inclusion
and exclusion criteria should be
clear enough so that those who
meet the inclusion criteria are able
to fairly and equitably participate
in the study. Researchers must be
objective and nonjudgmental. The
design and study protocol must
be unambiguous. Allowing self-
disclosure as an inclusion criterion
allows participants the freedom to
choose to participate and dimin-
ishes the potential for issues such
as coercion.
While it is possible to ensure
adequate protection of individu-
als who are doubly vulnerable, it is
19. important for institutional review
boards and researchers to establish
additional safeguards and use great-
er scrutiny when working with this
population. Individuals who are
doubly vulnerable have the right
to participate in research, and the
outcomes of those studies are im-
portant to the understanding of
and ability to design effective treat-
ment for these conditions.
suMMAry: A MOre
ethicAlly sOuND
viewPOiNt
Research with individuals who
abuse alcohol—regardless of their
classification as vulnerable or dou-
bly vulnerable—should be con-
ducted. This viewpoint depends
on the premise that all research
should be designed to ensure that
participants are protected, risks to
1. Rigorous ethical standards must be upheld in conducting
research, and
attention should be given to vulnerable populations when they
are used as
research participants.
2. Some individuals fall into more than one vulnerable
population, causing them
to be doubly vulnerable.
3. People who have maladaptive patterns of drinking should be
21. providers and researchers should
take care to examine their be-
liefs about people who abuse
alcohol. Stereotyping from nar-
row-minded belief systems could
lead to the exclusion of doubly
vulnerable groups from research
that is needed to provide the
very growth in scientific knowl-
edge that allows nurses and other
health care workers to step out
of preconceived beliefs. Such re-
search will enhance the delivery
of care in response to the unique
needs of vulnerable groups, who-
ever they might be.
The number of groups becom-
ing officially deemed vulnerable
continues to expand, making
virtually everyone vulnerable for
some reason. If arguments for not
conducting research with vulner-
able populations were to prevail,
the advancement of the body of
scientific knowledge could eas-
ily be halted. Such an outcome
clearly would not be in anyone’s
best interest.
If ethical guidelines are held
to the highest possible standards,
research with every population
will be ethical, and all popula-
tions can be included, which
will allow all individuals to reap
22. the benefits of ongoing research.
This contributes to the health of
all people, expansion of the body
of nursing knowledge, and im-
proved human existence.
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(1994). Diagnostic and statistical manu-
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Compton, P. (2002). Caring for an al-
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Retrieved from http://www.cioms.ch/
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Dick, D.M., Jones, K., Saccone, N., Hin-
richs, A., Wang, J.C., Goate, A., et al.
(2006). Endophenotypes successfully
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10policies/b3/index.html
Dr. Gwyn is Assistant Professor, De-
partment of Nursing, Florida Hospital
College of Health Sciences, Orlando,
and Dr. Colin is Professor and Director,
Nursing PhD, Nursing Administration,
and Nursing Education Programs, Barry
University, Division of Nursing, Miami
Shores, Florida.
The authors disclose that they
have no significant financial interests
in any product or class of products
discussed directly or indirectly in this
activity, including research support.
The authors acknowledge Rev. Lewis
R. Gwyn, III, and Barry University’s
Writing Center for their guidance and
editorial support in preparing the
manuscript.
Address correspondence to Priscilla
Gage Gwyn, PhD, ARNP-BC, OCN,
Assistant Professor, Department of
26. Nursing, Florida Hospital College of
Health Sciences, 671 Winyah Drive,
Orlando, FL 32803; e-mail: gage.
[email protected]
Received: March 22, 2009
Accepted: October 5, 2009
Posted: January 22, 2010
doi:10.3928/02793695-20100108-01
Journal of Psychosocial nursing • Vol. 48, no. 2, 2010 43
Reproduced with permission of the copyright owner. Further
reproduction prohibited without permission.
job Title: Director of Human Resources
Company: Zappos
Name:,,,,,,
Role #1: Being able to adapt to the quickly
changing needs of the market in which their
company runs. For the case of Hollie Delaney, she
has to be able to see how these changes affect
how her company and the employees that work
under her. This includes anything from
maintaining or changing the regular tasks that
their employees need to complete, but as regular
as their employees payrolls .Also, being able to
place newly hired employees in a training program
27. that will allow them to progressively excel
throughout their time with the company, allowing
new positions to be filled as others move up
within the company is a big role in Human
Resources.
Role #2: Running an applicable hiring system to
make sure that their company is brining in people
who are fit for the specific job title, and will be
able to work well within the company reins. This
also factors in the use of employee
recommendations and use of social media
checking as an extra way to provide evidence as
to who these employees are.
Role #3: Making sure that the employees of the
company are compensated, outside of a general
salary or paygrade. This includes various kinds of
insurance, working with basic employee relations,
providing benefits, and focusing on persistent
training that will keep the company growing as
time progresses.
https://www.smartrecruiters.com/blog/the-10-
most-influential-hr-practitioners/
https://www.thebalancecareers.com/what-does-
a-human-resources-manager-do-1918551
https://www.zapposinsights.com/speaking/
hollie-delaney
https://www.smartrecruiters.com/blog/the-10-most-influential-
hr-practitioners/
29. - At the conclusion of your post there should be at least four
APA cited references (1.
Referencing the job description, 2-4 references to support each
job duty that was
researched.)
As an example, I referenced the job description for the Human
Resources Director that
is located in the textbook on pages 10-11. The first job task I
chose to research was:
1) “Conducts and reviews wage and benefit surveys; proposes
employee benefit
modifications to the general manager”
I am unfamiliar with ‘wage and benefit surveys.’ According to
Coleman (n.d.),
compensation surveys are typically compiled by researchers the
determine the rate
of compensation for comparable jobs. Companies use this
information to
determine if they are providing competitive wages and benefits
to employees in
order to attract and retain the best employees. Therefore, I
would conclude that
according to this job description the Director of Human
Resources is responsible for
conducting and analyzing compensation surveys to determine if
any modifications
will need to be made in order to attract and retain the best
employees.
References:
Coleman, B. (n.d.). Compensation surveys. Salary.com.
30. Retrieved from http://
www.salary.com/compensation-surveys/
If you need a refresher on proper citation techniques the
following websites will be helpful:
▪ Purdue Owl Writing Lab
▪ APA Style
▪ IUP Reference Services
http://www.salary.com/compensation-surveys/
http://www.salary.com/compensation-surveys/
https://owl.english.purdue.edu/owl/
http://www.apastyle.org/
http://www.iup.edu/library/reference/
Sanagavarapu, Krishna
** Be prepared to discuss in class. I will be taking volunteers to
write some of their
findings on the board.