Wanted-nurses. Ethical issues and the nursing shortage

The persistent nursing shortage is challenging the values and beliefs of the nursing profession and causing nurses to ask how they can fulfill their ethical responsibilities to patients when there are an insufficient number and a maldistribution of nurses. Nurses are expressing job dissatisfaction, experiencing moral distress, and wondering about their inability to provide quality patient care. In this article, the author addresses the commitment to care for patients and the ethical dilemma with which nurses are grappling: caring for self versus caring for others. Recommendations for possible action include reenvisioning the profession of nursing, empowering nurses, providing support, and restructuring the work environment. Taken together, these actions have the potential to reduce the moral distress that nurses are experiencing and to enable them to honor their commitment to patient care.     

A socratic dialogue on the question 'what is love in nursing?

It is the thesis of the authors that the caring ethic and moral state of being of nurses ideally suffuses their professional caring and is thus implicit in their ethical decision making. Socratic dialogue is a technique that allows such moral attitudes to be made explicit. This article describes a Socratic dialogue conducted with nurses on the topic: 'What is love in nursing?' The conclusions drawn were based on the belief that the current western-style health care system restricts the practice of nursing in such a way as to limit professional caring and loving possibilities. Nurses who love in the practice of caring go beyond the role definition of the duty of care; they are people who are prepared to think differently about their practice as professionals, and are identified as competent risk takers committed to the betterment of the other. From this dialogue, 'love in nursing' was understood as the willingness and commitment of the nurse to want the good of the other before the self, without reciprocity.     

Perceptions and expectations of Baccalaureate-prepared nurses in Jordan: Community survey

The overall purpose of this paper is to describe the process of utilizing community participation for curriculum design to develop a new school of nursing. A brief Community Needs Assessment Survey was carried out in order to explore community perceptions and expectations of Baccalaureate-prepared nurses in Jordan. The sample consisted of 152 participants who were staff nurses, nurse administrators, nurse supervisors, nurse educators, physicians, pharmacists and consumers of services. Data were collected through a self-administered survey form using open-ended questions. Participants were asked to describe their perceptions of nursing and nurses, the desired professional skills and personal characteristics of the Baccalaureate-prepared nurse, important curriculum contents and to provide suggestions or comments for improving the preparation of Bachelor of Science in Nursing (BSN) nurses. The findings indicated that nursing was viewed as a caring profession where nurses care for the person both in sickness and health. Several professional skills and personal characteristics emerged as being important for the BSN nurse, including clinical competence, the desire to continue learning, communication skills, ethical and moral character, critical thinking, assessment skills, and computer and English-language skills. The participants provided the desired curriculum contents and suggestions related to the expected skills. Implications for nursing education were discussed.     

Ethics in critical care in nursing

The ANA Code for Nurses requires ethical behavior from all practitioners of nursing. As such, it serves to safeguard the public from unethical nurses. However, the code cannot and does not give direction in all situations nurses encounter in practice. Nurses require more assistance to meet the ethical requirements of professional practice. Careful exploration of moral principles and theories affords the nurse a broad background and some specific insights into morality and moral decision making. However, even this knowledge does not allow any nurse to put her ethical self "on automatic" while she appeals to one or another of these principles to support what she decides to do. No moral theory or principle is absolute. None can be used exclusively to resolve the many ethical questions nurses face. A nurse must use the process of reflective equilibrium to balance her own moral convictions and her background beliefs with accepted moral theories and principles, in order to reach sound moral judgements.     

Ethical issues in clinical research. Informed consent and risks versus benefits in the treatment of primary hypertension

Clinical research involves a number of ethical issues for the nurse researcher and clinician. When new treatments, such as experimental drugs, are used in patient care, the issues of informed consent to treatment and the balancing of risks and benefits may be especially difficult to resolve. By understanding the functions and elements of informed consent, nurses can assist their patients to ask for and to comprehend the information they need to be truly and fully informed about treatment choices. Likewise, assessing the risks and benefits of an experimental treatment option, such as an experimental drug for the treatment of primary hypertension, may be important to the long-term health of patients. Nurses assist patient decision making and the assessment of relevant risks and benefits by being fully informed about the planned research and by applying knowledge of ethical principles to patient care. When nurses incorporate this type of ethical reflection and moral skill into nursing practice, they meet minimal moral obligations to patients.     

The challenge of caring for patients in pain: from the nurse’s perspective

Aim. To increase understanding of what it is like for nurses to care for patients in pain. Background. Hospitalised patients are still suffering from pain despite increased knowledge, new technology and a wealth of research. Since nurses are key figures in successful pain management and research findings indicate that caring for suffering patients is a stressful and demanding experience where conflict often arises in nurses’ relations with patients and doctors, it may be fruitful to study nurses’ experience of caring for patients in pain to increase understanding of the above problem. Design. A phenomenological study involved 20 dialogues with 10 experienced nurses. Results. The findings indicate that caring for a patient in pain is a ‘challenging journey’ for the nurse. The nurse seems to have a ‘strong motivation to ease the pain’ through moral obligation, knowledge, personal experience and conviction. The main challenges that face the nurse are ‘reading the patient’, ‘dealing with inner conflict of moral dilemmas’, ‘dealing with gatekeepers’ (physicians) and ‘organisational hindrances’. Depending upon the outcome, pain management can have positive or negative effects on the patient and the nurse. Conclusions. Nurses need various coexisting patterns of knowledge, as well as a favourable organisational environment, if they are to be capable of performing in accord with their moral and professional obligations regarding pain relief. Nurses’ knowledge in this respect may hitherto have been too narrowly defined. Relevance to clinical practice. The findings can stimulate nurses to reflect critically on their current pain management practice. By identifying their strengths as well as their limitations, they can improve their knowledge and performance on their own, or else request more education, training and support. Since nurses’ clinical decisions are constantly moulded and stimulated by multiple patterns of knowledge, educators in pain management should focus not only on theoretical but also on personal and ethical knowledge.     

The old get equal care: myth or reality

A national ethics survey was conducted of all registered nurses participating in post-basic specialisation nursing courses in Israel over a one-year period (1994-95) to identify ethical situations which confront Israeli nurses caring for patients of different age groups and in different clinical settings. This study compares the responses of those nurses caring for elderly patients (60 years or older) with those caring for adult patients in other age groups. Nurses caring for the elderly reported encountering ethical dilemmas in 16 out of 37 situations presented to them, more than in the other adult patient age groups. The most frequent dilemmas were concerning mistaken or questionable treatment, patient-family conflict, patient referral to an institution or discharge to the home where the family is incapable of caring for him, offensive behaviour by caregivers and physical restraint of the patient for staff convenience. It is recommended that nursing ethics intervention programmes be established to promote ethical decision making and patients' rights.     

Perioperative nursing: moral and ethical issues in high--technology practice

The caring component of perioperative nursing practice entails responsibility and accountability for nurses to identify and address the moral/ethical issues inherent in the practice. Ethical/moral issues in perioperative nursing are becoming more complex as technology becomes more sophisticated, financial resources become more restricted, and choices regarding care occur in an ambiguous environment. The practice environment must provide processes by which nurses can examine the ethical/moral choices made or to be made both to support the nurse and to increase the body of knowledge of perioperative nursing practice.     

Unity of knowing and action- exploring moral courage in nursing practice

Ethics is a core value of nursing, and hospital nurses will try, as much as possible, to be "good" in terms of established nursing ethics and values. Nurses learn the value of providing "patient centered care" in school and try to establish relationships of trust with their patients in clinical settings. However, the realities of working in the hospital teaches nurses that actual situations are complex to the point of inducing "ethical dilemmas" and "moral distress" because of the many factors that affect medical decisions regarding individual patients. If nurses could follow their conscience in managing difficult ethical situations with moral courage, they would promote the value of "good nurse" which is innate in both nurses and society. This article defines the parameters of conscience and moral courage, the conditions such should exhibit, strategies nurses should consider, and appropriate nursing training methods. The authors hope to help foster the development of moral courage and create positive practice environments for nursing staff.     

Challenging times: ethics,nursing and the COVID-19 pandemic

Globally nurses and midwives are working hard to detect cases of COVID-19, to save lives or give comfort in the face of death, to educate themselves and the public about protective measures to stop the viral spread, while still caring for those not infected with the virus. In many countries nurses are working under virtual siege from this pandemic, with not enough resources or personal protective equipment, overwhelming numbers of patients, staff shortages, underprepared health systems and supply chain failures. Nurses and other health and emergency workers are suffering physical and emotional stress, and moral distress from conflicting professional values. They are faced with unpalatable and complex ethical issues in practice, with moral conflicts, high levels of acuity and patient deaths, and long working hours. A rising number of nurses are infected with SARS-CoV-2 or dying in the line of duty. Nurses need strong moral courage, stamina and resilience to work on the front lines of the pandemic, often while separated from their loved ones.     

‘The nurse should consider.’ Critical care ethical issues*

A hypothetical dilemma on resuscitation of an intensive care patient was presented to nurses at a workshop on ethics of critical care nursing. Nurses responded to separate questionnaires about what a charge nurse should do, and what they themselves would do in relation to ten considerations arising from the dilemma. Nurses were agreed that legal consequences, patient wishes and rights, and physician authority should and would be considered, and that peer influence should not. Nurses were divided in their attitudes to following procedure and personal moral beliefs, and to job risk. The most contentious issues were related to the nurse's role as a decision-making member of the health care team. Implications for regarding nurses as independent decision-makers are discussed.     

Ethical challenges in the care of older people and risk of being burned out among male nurses

Aim. The aim of this study was to illuminate the meaning of being in ethically difficult situations when caring for older people, as experienced by male nurses. Background. Nurses and physicians are frequently faced with ethical issues and challenges in their work with older people in hospitals. Male nurses are a minority group in the nursing profession, thus it is important to listen to their lived experiences of the ethical challenges they are faced with in their work. Method. The study is part of a comprehensive investigation into the narratives of female and male physicians and nurses, concerning their experiences of being in ethically difficult care situations in the care of older people. Five male nurses working at gerontology wards at a university hospital in Norway participated in the study. A phenomenological hermeneutical method was applied. Results. The narratives revealed that the nurses were focusing on good nursing, emphasizing what meeting the patient entails. They highlighted what they perceived as barriers to good nursing. A third theme was ethical challenges, which lead to emotional and moral strain and a fear of becoming burned out. Conclusions. Continuous stress, little degree of autonomy and high expectations of oneself are causing the male nurses much moral strain. These factors place them at risk of being burned out. The nurses emphasized that burn out can be counteracted by clinical supervision. Relevance to clinical practice. It is suggested that the male nurses feeling of doing an important and rewarding job may be essential for protection against becoming burned out and why they can endure being in ethically difficult care situations. Other institutional support structures like ethics education and ethics rounds are suggested to reduce the level of moral strain.     

Navigating the evidence-based practice maze

Aim  This article's purpose is to provide nurses with key points to consider in facilitating informed decision making while navigating the evidence-based practice (EBP) maze.
Background  EBP in nursing evolved from the medical model and continues developing within the holistic nursing paradigm. Inconsistent terminology, multiple applications, and lack of a unifying theory create challenges for nurses.
Key issues  Recognition that multiple knowledge sources to support clinical decision making have merit for facilitating 'best' patient outcomes; EBP must be an internalized value of professional nursing.
Conclusions  Multiple ways of knowing, or evidence, for informed clinical decision making must be considered based on situational context. No hierarchy fits all situations. Nurses must provide support and resources to facilitate nurse empowerment; nurses are accountable for using EBP to enhance patient outcomes.
Implications for nursing management  Effective EBP implementation relies on nurses being cognizant of what current nursing EBP trends are based on and where they are going. Nurses have a key role in facilitating consensus regarding evidence to be used in EBP, and ensuring availability of resources for empowering nurses to be accountable for outcome-oriented patient care through utilizing EBP.     

From self‐compassion to compassionate action: reflecting on ending life of stillbirth care in nursing

Nurses’ distress in response to the professional experience of the neonatal loss and stillbirth care is poorly addressed in nursing practice; therefore, the purpose of this study is to explore nurses’ experiences of labour of a stillborn baby. A qualitative approach with ten Registered Nurses from hospital birth units in northern Taiwan was used to investigate the stillbirth care experiences of nurses. Research data analysed by interpretative phenomenological analysis (IPA) were collected from eight digital recorded sessions of group dialogues, nurses' responses and feedbacks. Three main themes extracted from data include unfolding the suffering, engrossing in stillborn parents and demonstrating compassionate actions for the stillborn baby. Unfolding the suffering includes shame, guilt and disenfranchised grief. Engrossing in stillborn parents includes perceiving the mother’s suppress sadness and empathising with the father’s anger. Finally, demonstrating compassionate actions includes fulfilling the parents’ needs to say goodbye to their stillborn baby and saying a personal goodbye to the dead baby. The finding of this study shows that the reflective group provided the space for nurses to unfold their suffering, share their emotion, and develop practical wisdom in caring for stillborn baby and the parents. The experience of nurse group conducting the reflecting dialogues could be a expository strategy to promote the nurse to provide the compassionate care actions.     

Acquired immunodeficiency syndrome: the nurse's legal duty to serve.

Some nurses are reluctant to care for human immunodeficiency virus (HIV)-infected clients because of fear of contagion and discomfort in caring for people with alternate life-styles. Various federal, state, and local antidiscrimination statutes limit the right of the nurse to refuse to care for people with acquired immunodeficiency syndrome (AIDS) or HIV infection. Other constraints are employment contracts, ethical codes of professional organizations, and regulations of state licensing boards. Nurses have rights as well as responsibilities in caring for AIDS or HIV-infected patients. They also have a professional responsibility to institute measures that minimize the need for litigation and ensure access to health care for everyone.     

Existential caring in the family health experience: a proposed conceptualization

Empirical realities and technological advances in the clinical practice context continuously call for ethical dialogue among healthcare providers. The nurse's voice of advocacy for humane caring grounded in an existential understanding of the complexities of the health experience remains a salient responsibility of moral agency. If nurses are to care for families, as society requires, then nurse caring, a phenomenon currently defined and understood primarily at the individual patient-nurse level, must be diligently and broadly explored in terms of its worth to guide nursing service with families. The purpose of this theoretical paper is to explore a conceptualization of care with families in the health experience that emanates from the philosophical tenets of existentialism and underpinnings of symbolic interactionism and is interpreted into action by the ethics of care. Current and classic literature, inclusive of philosophical and empirical works, provide the background for analysis of the following elements: existential caring orientation, family perspective, family-nurse interaction, construction of meaning, family meaning construction, nurse meaning construction, family-nurse co-construction of meaning and existential advocacy. Existential philosophy is understood as the basic underlying lens guiding the nurse in taking an existential caring orientation as depicted in the resultant conceptualization. Caring in the family health experience is best facilitated by a relational stance where the nurse acknowledges the family's unique perspective. Through the family-nurse interaction the nurse gains understanding of the family's perspective being constructed. Nursing practice with families confronting the empirical realities and technological advances of the new millennium will be enriched when moral agency includes ethical dialogue among healthcare providers and families. Existential advocacy with and for families grounded in the nurse's understanding of the family perspective enhances the context for moral agency.     

Nursing's image on the university campus

Our study found that the faculty sampled held a different and more positive view of nursing than the one presented by the media. Nurses were perceived as educated, autonomous and compassionate individuals whose role is vital in health care. These findings might be explained by the high degree of personal contact that the sample had with nurses. It is possible that personal contact with nurses may mediate against the negative media image of nursing. As one respondent wrote, "Nursing care after recent surgery certainly erased all stereotyped notions...." The implications are tremendous for the role of the nurse in every encounter with the public. Nursing's energies might be best directed toward promoting nursing, not as it is portrayed in the media world of make-believe, but as it is lived by real nurses and their clients. Nurses must convey an image of caring, competent professionals who are capable of addressing society's health care needs. In the words of another respondent, "Unfortunately, the American public does not know the reality of professional nursing and the nurses have been treated unfairly, far from what they deserve.... I hope the American public will look on nursing as one of the most respectable professions and give the nurses credit for their efforts, devotion, and knowledge...."     

Ethical components of caring

The meanings of caring that emerge from the ethics literature are professional value; personal value; understanding humankind's existence; understanding meaning of values, choices, and priority systems; moral decision making; dignity; worth; healing powers within; being treated as a person; and partners in treatment. These meanings of caring are incorporated into the practice realm of critical care nurses. Clients in the critical care units demand a nurse who will treat them with respect, understanding, dignity, worth, partnership; provide choices; understand their values; guide them in moral decision making; and empower their healing capacities. As technology continues to explode, more and more ethical dilemmas will evolve and the critical care nurse will need to bridge the advancing technology with human caring. Then her expert nursing care will make the empowering difference in the client's care.     

New developments in international nursing ethics

This article has described numerous activities in nursing ethics at international levels. It acknowledges the larger context within which nurses practice by focusing on selected issues involved in resource allocation and death and dying, cross-culturally. The questions raised about universally shared moral principles reflects the larger questions of cultural and ethical relativism. The discussions of new developments in international nursing ethics focuses on international conferences, the teaching of nursing ethics, national nursing associations, and other professional groups that are actively involved in health care or nursing ethics. Finally, the development of international nursing ethics research studies is providing new knowledge about the scope of ethics within nursing and the nature of nursing care worldwide. Nurses are involved in some aspects of these new developments in nursing ethics in all countries. As they examine and reflect on ethical principles, virtues, and on an ethics of caring, they bring a new dimension to their work as nurses. This new dimension stands as one of the oldest and most central foundations in professional nursing.     

The "right" to a caring relationship: the law and ethic of care

The ethic of care is often described as the ethical basis for nursing. While ethics and legal issues are related, it is unclear if perinatal nurses apply this theoretical relationship to clinical practice. There is evidence that medical malpractice litigation may be motivated by dissatisfaction with the caring relationship. A patient's moral "right" to a caring relationship, barriers in clinical practice to caring relationships, and legal remedy for perceived violation of the right to a caring relationship are discussed. Nurses must promote sound caring relationships and articulate to others the impact on perinatal outcomes and legal liability.