Moral responsibility: a relational way of being

This article reports a study exploring the meaning of the complex phenomenon of moral responsibility in nursing practice. Each of three focus groups with a total of 14 student nurses were conducted twice to gather their views on moral responsibility in nursing practice. The data were analysed by qualitative thematic content analysis. Moral responsibility was interpreted as a relational way of being, which involved guidance by one's inner compass composed of ideals, values and knowledge that translate into a striving to do good. It was concluded that, if student nurses are to continue striving to do good in a way that respects themselves and other people, it is important that they do not feel forced to compromise their values. Instead they should be given space and encouragement in their endeavours to do good in a relational way that advances nursing as a moral practice.     

Listening to nurses' moral voices: building a quality health care environment

In this paper we describe a research project in nursing ethics aimed at exploring the meaning of ethics for nurses providing direct care with clients. This was a practice-based project in which participants who were staff nurses, nurses in advanced practice, and students in nursing were asked to tell us (or describe to us) how they thought about ethics in their practice, and what ethical practice meant to them. We then undertook to analyze, describe and understand the enactment of ethical practice, the opportunities for and barriers to such enactment, as well as the resources nurses need for ethical practice. We drew out implications of these findings for nursing leaders. We identified practice realities that create a climate for ethical or moral distress, and the way in which nurses attempt to maintain their moral agency. Practice realities included nurses' ethical concerns about policies guiding care; the financial, human and temporal resources available for care; and the power and conflicting loyalties nurses encounter inproviding good care. Maintaining moral agency involved use of a variety of ethical resources and the identification of resources needed to provide good care, as well as the processes used to enact moral agency. Nurse leaders are also moral agents. Important implications of these findings for nursing leaders are that they need moral courage to be self-reflective, to name their own moral distress, and to act so that their nursing staff are able to be moral agents. Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent and ethical practice.     

Relational and embodied knowing: nursing ethics within the interprofessional team

In this article we attempt to situate nursing within the interprofessional care team with respect to processes of ethical practice and ethical decision making. After briefly reviewing the concept of interprofessionalism, the idea of a nursing ethic as 'unique' within the context of an interprofessional team will be explored. We suggest that nursing's distinct perspective on the moral matters of health care stem not from any privileged vantage point but rather from knowledge developed through the daily activities of nursing practice. Because of their position vis-à-vis patients and families in everyday clinical care, nurses cultivate ethical knowledge of at least two forms: (1) relational knowledge; and (2) embodied knowledge. Through the integration of these forms of knowledge, nurses develop a unique moral perspective and can make a meaningful contribution to the realm of ethics in interprofessional care.     

Autonomy and advocacy in perinatal nursing practice

Advocacy has been positioned as an ideal within the practice of nursing, with national guidelines and professional standards obliging nurses to respect patients' autonomous choices and to act as their advocates. However, the meaning of advocacy and autonomy is not well defined or understood, leading to uncertainty regarding what is required, expected and feasible for nurses in clinical practice. In this article, a feminist ethics perspective is used to examine how moral responsibilities are enacted in the perinatal nurse-patient relationship and to explore the interaction between the various threads that influence, and are in turn affected by, this relationship. This perspective allows for consideration of contextual and relational factors that impact on the way perinatal nursing care is given and received, and provides a framework for exploring the ways in which patient autonomy, advocacy and choice are experienced by childbearing women and their nurses during labour and birth.     

How nurses’ use of language creates meaning about healthcare users and nursing practice

Nursing practice occurs in the context of conversations with healthcare users, other healthcare professionals, and healthcare institutions. This discussion paper draws on symbolic interactionism and Fairclough's method of critical discourse analysis to examine language that nurses use to describe the people in their care and their practice. We discuss how nurses’ use of language constructs meaning about healthcare users and their own work. Through language, nurses are articulating what they believe about healthcare users and nursing practice. We argue that the language nurses use can contribute to viewing their practice as tasks on bodies that must be accomplished efficiently and objectively within the biomedical model, rather than relational and person‐centered. Moreover, the language nurses use can perpetuate a sense of powerlessness within healthcare systems yet paradoxically they are in a position of power over healthcare users. Nurses’ compliance with the efficiency and biomedical model results in a lack of emphasis on the full breadth of nursing work, which could be enacted in relational rather than power‐laden practices. We conclude by positing that careful use of language among nurses in all settings is essential, if we are to begin to articulate what nursing is to ourselves and to others.     

Ethical dilemmas and moral distress in oncology nursing practice

Although ethical values and principles guide oncology nursing practice, nurses often are challenged to fulfill every professional core duty and responsibility in their everyday practice. Nurses commonly encounter clinical situations that have ethical conflicts, and they often have difficulty recognizing and articulating them. Unresolved conflicts can cause feelings of frustration and powerlessness, which can lead to compromises in patient care, job dissatisfaction, disagreements among those in the healthcare team, and burnout. This article reviews the ethical principles and values individual nurses bring to their practice as well as those basic to the profession of nursing. This article also discusses ethical conflicts in oncology practice and describes how nurses, especially students and novice nurses, may react to such situations with moral uncertainty or distress. In addition, a process for analyzing and resolving ethical problems in clinical situations is outlined. Increasing awareness and dialogue about ethical issues is an important first step in the process. Additional resources in the clinical setting may encourage nurses to actively participate in ethical decision making and take deliberate action as moral agents.     

Doing the right thing: nursing students, relational practice, and moral agency

Registered nurses and nurse educators are often unaware of how nursing students experience the nursing profession. In the current practice climate of increased workloads, reduced funding, and higher patient acuity, nurse educators are likely to hear from colleagues how unprepared newly qualified nurses are for the needs of practice. It is difficult for many nursing students to see value in their practice because they become preoccupied with their perceived lack of knowledge and technical skills. Nurses and nurse educators should be aware of how this brands new graduates and informs their sense of developing professional identity. Despite their feelings of deficit in terms of skills and knowledge, it is clear that many nursing students are, in fact, effectively negotiating relational ethics. This article presents a collaborative account of the important relational work being undertaken by one group of nursing students in New Zealand.     

Nurses and national socialism--a moral dilemma: one historical example of a route to euthanasia

If euthanasia were to be made legal in other countries apart from The Netherlands and Belgium, nurses would be faced with ethical dilemmas that could impact on their professional accountability and their personal moral beliefs. As a part of history has demonstrated, the introduction of the practice of euthanasia could also significantly change the relationship between nurses and patients. In Germany between 1940 and 1945, in response to a government directive, nurses participated in the practice of euthanasia and as a result many innocent German people were killed by what were considered to be 'mercy deaths'. It is important to try and understand the moral thinking and examine the complex issues at this historical junction that led German nurses to participate in the killing of thousands of innocent people. Such reflection may help to stimulate an awareness of the moral issues that nurses in the twenty-first century could confront if euthanasia were to be made legal in their own country. This has implications for future nursing practice.     

Beyond and around mandatory reporting in nursing practice: Interrupting a series of deferrals

Nurses are well positioned to contribute to child protection efforts but are underutilised. This paper describes a critical discursive analysis of nursing responses to child neglect and abuse (CN&A) in British Columbia, Canada. Legal and practice guidelines were analysed alongside nurse interview texts, offering a glimpse into how nurses prevent CN&A in their everyday practice with families. Results show how the primacy of mandatory reporting to child protection authorities coordinates a series of deferrals and how nurses engage with and interrupt these deferrals in everyday practice. Nurses' relational approaches are essential to gain access to the private sphere of the family to assess, plan, elicit cooperation with interventions and monitor the situation. They considered reporting to be one among many possible responses. This study highlights how nursing contributions to prevention are largely overlooked and points to the potential for a more significant role for nurses in a public health approach to child protection.     

The professional development of nursing through different aspects of the caring practices of nurses: nursing the patient person in a geriatric assessment unit

The caring component of nursing practice has become an increasingly visible activity of nursing. Consequently, a growing amount of research has explored the role caring plays in nurse practice. Research often explores the activities of caring or its moral agenda, rather than motivation. This study broadens the discussion about nurses and caring practice by examining nurses approaches to different aspects of the caring practices of nurses for the aged in a Geriatric Assessment Unit (GAU). Data collection involved semi-structured interviews and participant observation within the GAU. Four categories of themes emerged as different aspects of the caring practices of nurses. Three fit within the professional development of nursing: physical caring, negotiative caring and relational caring. A fourth, motivated caring, however, provides an additional aspect of caring located within and beyond professional development.     

Nurses' responses to ethical dilemmas in nursing practice: meta-analysis

Title. Nurses’ responses to ethical dilemmas in nursing practice: meta‐analysis. Aim. This paper is a report of a study to explore nurses’ responses to ethical dilemmas in daily nursing practice. Background. Concern about nurses’ ethical competence is growing. Most nurses perceived that there were barriers in their work environment to ethical practice, compromising their ability to perform ethically. Since most research focuses on contextual barriers to nurses’ ethical practice, little is known about how nurses involve themselves in ethical decision‐making and action in daily care. Method. A meta‐analysis of nurses’ ethical behaviour was conducted using data from nine studies in four countries (n = 1592 registered nurses). In all studies, the Ethical Behaviour Test was used to measure nurses’ ethical responses, based on an adapted version of Kohlberg’s theory of moral development. Data were analysed using random‐intercept regression analysis. Findings. All groups, except the expert group, displayed a uniform pattern of conventional ethical reasoning and practice. When nurses were faced with ethical dilemmas, they tended to use conventions as their predominant decision‐guiding criteria rather than patients’ personal needs and well‐being. Conclusion. Conformist practice (following conventions rather than pursuing good for the patient) constitutes a major barrier for nurses to take the appropriate ethical actions, as creativity and critical reflection are absent. There is an urgent need to find ways to promote nurses’ ethical development from conventional to postconventional ethical practice. More research is needed to strengthen existing empirical evidence.     

Relational ethics and advocacy in nursing: literature review

AIM: The purpose of this paper is to analyse themes from accounts of nurses' experiences with advocacy that may expand our understanding of advocacy in nursing practice. BACKGROUND: Although the ethical obligation to advocate is universal, a lack of clarity persists about the nature of advocacy in nursing practice. METHOD: This discussion of advocacy is based on a synthesis of qualitative studies that focus on nurses' experiences with advocacy in practice. Empirical studies were retrieved through searches on the CINAHL and Academic Search Premier databases for the years 1993-2005. The search terms used were advocacy, advocate role, ethics, nursing practice and qualitative research. FINDINGS: Empirical studies related to the role of advocacy in nursing are limited in number. Nurses' experiences with advocacy reveal important themes in relation to factors that influence the application of advocacy in nursing practice. Evidence suggests that the nature and context of relationships plays a significant role in influencing the enactment of advocacy. CONCLUSION: The application of advocacy in nursing practice is complex. The philosophy of relational ethics emphasizes the contextual features of relationships. An examination of relational ethics as it applies to advocacy in nursing brings us closer to a deeper understanding of the process by which nurses make advocacy choices in practice, and raises implications for the development of advocacy in nurses' practice. Advocacy is universally considered a moral obligation in nursing practice, and thus advancement of our knowledge about its nature in nursing is relevant to nursing across multiple contexts and cultures.     

Caring about--caring for: moral obligations and work responsibilities in intensive care nursing

The aim of this study was to analyse experiences of moral concerns in intensive care nursing. The theoretical perspective of the study is based on relational ethics, also referred to as ethics of care. The participants were 36 intensive care nurses from 10 general, neonatal and thoracic intensive care units. The structural characteristics of the units were similar: a high working pace, advanced technology, budget restrictions, recent reorganization, and shortage of experienced nurses. The data consisted of the participants' examples of ethical situations they had experienced in their intensive care unit. A qualitative content analysis identified five themes: believing in a good death; knowing the course of events; feelings of distress; reasoning about physicians' 'doings' and tensions in expressing moral awareness. A main theme was formulated as caring about--caring for: moral obligations and work responsibilities. Moral obligations and work responsibilities are assumed to be complementary dimensions in nursing, yet they were found not to be in balance for intensive care nurses. In conclusion there is a need to support nurses in difficult intensive care situations, for example, by mentoring, as a step towards developing moral action knowledge in the context of intensive care nursing.     

Ethical and moral considerations of (patient) centredness in nursing and healthcare: Navigating uncharted waters

This discussion paper aims to explore potential ethical and moral implications of (patient) centredness in nursing and healthcare. Healthcare is experiencing a philosophical shift from a perspective where the health professional is positioned as the expert to one that re‐centres care and service provision central to the needs and desires of the persons served. This centred approach to healthcare delivery has gained a moral authority as the right thing to do. However, little attention has been given to its moral and ethical theoretical grounding and potential implications for nurses, persons served and the healthcare system. Based upon a review of academic and grey literature, centredness is proposed as a value‐laden concept in nursing inquiry. Potential moral and ethical implications of centredness on nurses/healthcare providers, persons served and the healthcare system are discussed. These challenges are then considered within the context of normative and relational ethical theories. These perspectives may offer guidance relative to how one should act in those circumstances as well as an understanding as to how interdependency and engagement with the other person(s) can help navigate the challenges of a centred care approach. Viewing centredness through an ethical theoretical lens provides a valuable discourse to nursing in efforts to expand the knowledge base and integrate centred approaches into practice and policy.     

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.     

Moral distress among Ugandan nurses providing HIV care: A critical ethnography

Background

The phenomenon of moral distress among nurses has been described in a variety of high-income countries and practice settings. Defined as the biopsychosocial, cognitive, and behavioural effects experienced by clinicians when their values are compromised by internal or external constraints, it results from the inability to provide the desired care to patients. No research has been reported that addresses moral distress in severely resource-challenged regions such as sub-Saharan Africa.

Aim

To describe the manifestation and impact of moral distress as it was experienced by Ugandan nurses who provided care to HIV-infected or -affected people.

Method

A critical ethnography was conducted with 24 acute care and public health nurses at a large referral centre in Uganda. Data were collected through interviews, observation, and focus group discussions.

Results

Participants described their passion for nursing and commitment to patients. They experienced moral distress when a lack of resources put patients’ wellbeing at risk. The trauma imposed by systemic challenges on the nursing profession was acknowledged, as was the perception that the public blamed nurses for poor patient outcomes. However, participants were determined to serve to the best of their abilities and to take satisfaction from any contributions they were able to make. They cited the importance of education in the development of their capacity to provide care with a positive attitude, and demonstrated a collective resilience as they discussed strategies for addressing issues that affected them and their colleagues.

Conclusions

The experience of moral distress among nurses in Uganda differed somewhat from the experience of nurses in high-income countries. Constraints imposed by the inability to implement skills and knowledge to their fullest extent, as well as a lack of resources and infrastructure may result in the omission of care for patients. Moral distress appears to manifest within a relational and contextual environment and participants focussed on the impact for patients, communities, and the nursing profession as a whole, rather than on their own personal suffering. The opportunity for continuing education led to strategies to transform personal attitudes and practice as well as to enhance the presentation of the profession to the public.