Workplace distress and ethical dilemmas in neuroscience nursing

This study concerns Swedish nurses' experiences of workplace stress and the occurrence of ethical dilemmas in a neurological setting. Qualitative interviews were conducted with 21 nurses. The interview results were subjected to qualitative latent content analysis and sorted into 4 content areas: workplace distress, ethical dilemmas, managing distress and ethical dilemmas, and quality of nursing. Common workplace stressors were high workload and lack of influence. These were perceived to have negative consequences for the quality of nursing. Ethical dilemmas mainly concerned decision making on initiation or withdrawal of treatment, which was experienced as a troublesome situation where conflicts could arise. The nurses managed the distress and ethical dilemmas by accepting and adjusting to the situation and seeking support from colleagues. They also endeavored to gain new strength in their private lives.     

Nurses' workplace distress and ethical dilemmas in Tanzanian health care

The aim of this study was to describe Tanzanian nurses' meaning of and experiences with ethical dilemmas and workplace distress in different care settings. An open question guide was used and the study focused on the answers that 29 registered nurses supplied. The theme, ;Tanzanian registered nurses' invisible and visible expressions about existential conditions in care', emerged from several subthemes as: suffering from (1) workplace distress; (2) ethical dilemmas; (3) trying to maintaining good quality nursing care; (4) lack of respect, appreciation and influence; and (5) a heavy workload that did not prevent registered nurses from struggling for better care for their patients. The analysis shows that, on a daily basis, nurses find themselves working on the edge of life and death, while they have few opportunities for doing anything about this situation. Nurses need professional guidance to gain insight and be able to reflect on their situations, so that they do not become overloaded with ethical dilemmas and workplace distress.     

Chinese nurses' ethical concerns in a neurological ward

Our aim was to describe Chinese nurses' experiences of workplace distress and ethical dilemmas on a neurological ward. Qualitative interviews were performed with 20 nurses. On using latent content analysis, themes emerged in four content areas: ethical dilemmas, workplace distress, quality of nursing and managing distress. The ethical dilemmas were: (1) conflicting views on optimal treatment and nursing; (2) treatment choice meeting with financial constraints; and (3) misalignment of nursing responsibilities, competence and available resources. The patients' relatives lacked respect for the nurses' skills. Other dilemmas could be traced to the transition from a planned to a market economy, resulting in an excessive workload and treatment withdrawal for financial reasons. Lack of resources was perceived as an obstacle to proper patient care in addition to hospital organization, decreasing the quality of nursing, and increasing moral and workplace distress. The nurses managed mainly by striving for competence, which gave them hope for the future.     

Caring for dying infants: experiences of neonatal intensive care nurses in Hong Kong

Ten registered nurses working in a neonatal intensive care unit in Hong Kong were interviewed to explore their experiences of caring for infants whose disease is not responsive to curative treatment, their perceptions of palliative care, and factors influencing their care. Eight categories emerged from the content analysis of the interviews: disbelieving; feeling ambivalent and helpless; protecting emotional self; providing optimal physical care to the infant; providing emotional support to the family; expressing empathy; lack of knowledge and counselling skills; and conflicting values in care. The subtle cultural upbringing and socialization in nurse training and workplace environment also contributed to their moral distress. Hospital and nurse administrators should consider different ways of facilitating palliative care in their acute care settings. For example, by culture-specific death education, peer support groups, bereavement teams, modification of departmental policies, and a supportive work environment. Future research could include the identification of family needs and coping as well as ethical decision-making among nurses.     

Ethical issues and new nurses: preventing ethical distress in the work environment

As new nurses move from the familiar educational milieu into a work situation they encounter barriers to caring for patients and their families. The characteristics of the contemporary work environment, paired with the competencies of the new graduates, have the potential to threaten the ability of these nurses to provide safe and effective care for patients thus creating ethical distress. Educational interventions in the work place can effectively provide adequate solutions to these problems. The keystone between the healthcare institution and the development of a competent nurse is an effective mentor. As new nurses graduate from school and enter the health care industry they encounter many barriers that distract them from caring for their patients. With limited experience they are ill equipped to prevent ethical distress when confronted with ethical dilemmas. Educational strategies such as an adequate orientation can help a new graduate cope with the complexities of a health care industry confronted by an increase in acuity of patients, progressively more complex medical interventions, and a shortage of nurses.     

Ethical Dilemma and Moral Distress: Proposed New NANDA Diagnoses

PURPOSE: To propose two NANDA diagnoses--ethical dilemma and moral distress--and to distinguish between the NANDA diagnosis decisional conflict and the proposed nursing diagnosis of ethical dilemma. SOURCES USED: Journal articles, books, and focus group research findings. DATA SYNTHESIS: Moral/ethical situations exist in health care. Nurses' experiences of ethical dilemmas and moral distress are extrapolated to the types and categories of ethical dilemmas and moral distress that patients experience and are used as the basis for development of two new nursing diagnoses. CONCLUSION: The two proposed NANDA diagnoses fill a void in current standardized terminology. PRACTICE IMPLICATIONS: It is important that nurses have the ability to diagnose ethical or moral situations in health care. Currently, NANDA does not offer a means to document this important phenomenon. The creation of two sets of nursing diagnoses, ethical dilemma and moral distress, will enable nurses to recognize and track nursing care related to ethical or moral situations.     

Sources of occupational stress and coping strategies among nurses working in AIDS care.

Nurses working in AIDS care experience high rates of occupational stress and therefore are vulnerable to emotional exhaustion and occupational burnout. This study surveyed 499 members of the Association of Nurses in AIDS Care regarding their work-related stress experiences and coping strategies for managing stress. Qualitative analyses identified a hierarchical structure of occupational stress, with two supraclusters representing workplace and patient care-related stress and eight specific subclusters of stressors: institutions, personnel, biohazards, death, informing patients, challenging patients, families, and treatment dilemmas. Analyses showed that nurses experiencing stress from their workplace were significantly more likely to use wishful thinking, planful problem solving, and avoidance as coping strategies, whereas stress originating from patient care was more likely to be dealt with using positive appraisal and acceptance. Interventions designed to assist nurses in managing occupational stress and to prevent occupational burnout must include the sources of work-related stress among nurses in AIDS care.     

The faceless encounter: ethical dilemmas in telephone nursing

Aim. This paper aims to present the findings of a study designed to describe ethical dilemmas, in the form of conflicting values, norms and interests, which telenurses experience in their work. Background. Telephone nursing is an expanding part of health care. Telephone nurses in Sweden assess care needs, provide advice, support and information, and recommend and coordinate healthcare resources. Lately, ethical demands on healthcare professionals in general have increased. The reasons include new biomedical competence, an ageing population and constrained resources which have made priority setting a primary concern for doctors and nurses. When ethical problems arise, colleagues need open dialogue. Despite this, nurses lack such a dialogue. Method. A purposeful sample of 12 female telenurses in Sweden was interviewed twice during 2004 and 2005. The transcribed interviews were analysed thematically. Results. Five themes were found: talking through a third party; discussing personal and sensitive problems over the phone; insufficient resources and the organization of health care; balancing callers’ information needs with professional responsibility; and differences in judging the caller's credibility. Conclusion. The present study has identified five different themes in which Swedish telenurses experience ethical dilemmas in their work. This shows how ethical dilemmas in various forms are present in telenursing. Questions of autonomy, integrity and prioritizing are particularly highlighted by the participating nurses. Telenurses in Sweden also experience new ethical demands due to a multicultural society. Although several of the identified dilemmas also occur in other areas of nursing we argue that these situations are particularly challenging in telenursing. Relevance to clinical practice. The work organization should provide opportunities for ethical competence‐building, where ethical dilemmas in telenursing are highlighted and discussed. Such a strategy might lead to decreased moral uncertainty and distress among telenurses, with positive consequences for callers.     

A moral imperative to improve the quality of work-life for nurses: building inclusive social capital capacity

The complexity and incessant change in the corporatised health care workplace has influenced nurses' work choices, morale, quality of work-life and the wellbeing of patients. Thus, there is an urgent moral imperative to improve the quality of work-life for nurses. To this end, it is crucial to re-define progress beyond the sole economic markers of success and profit in the health care workplace. This paper argues for the identification of ethical markers and indicators of organisational success based on bridging and linking social capital which could be used to re-organise health care organisations, hence crafting inclusive moral spaces where nurses can safely work and provide quality care for patients. Social and ethical evaluation is well suited to examine current workplace dilemmas from a psychosocial perspective and provide a framework for best practice in building capacity in effective social relations and family friendly, ethical workplaces.     

La experiencia emocional de enfermeras de la Unidad de Hospitalización a Domicilio en cuidados paliativos: un estudio cualitativo exploratorio

ObjectiveTo explore the emotions experienced by the nurses of a Home Hospitalization Unit as a result of their work role.MethodA qualitative exploratory study was carried out with a phenomenology approach to explore people's experiences and inner-life experiences. The participants were 9 nurses working in the home hospitalization unit. An analysis of qualitative content was undertaken. Units of meaning were grouped into 13 codes that, in turn, were classified into 4 categories, emotional dimension, beneficial and distressing aspects, daily working life and personal life.ResultsNursing professionals working in palliative care suffer continuous exposure to traumatic situations, although they also report feeling satisfactory emotions that compensate for moments of distress. Having resources such as training in self-care and emotional regulation, as well as social support seems to be key to providing quality care and avoiding the onset of compassion fatigue.ConclusionsMaintaining psychosocial well-being in the workplace is crucial for palliative care nurses to be able to undertake their work in the best possible way.     

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.     

Moral distress: a pervasive problem

The shortage of nurses and the flaws within the structure of the current health care system are compromising the nurse's ability to provide competent, compassionate care. Nurses are increasingly disturbed because they see themselves as ineffective advocates for their patients. Nurses, unable to take the appropriate ethical actions, feel paralyzed by their situation. The author's recent conversations with staff nurses about their clinical practice suggest that moral distress has become a very pervasive problem. The purpose of this article is to describe ethical practice, moral distress, the imbalance of power, and the nature of an ethical environment. There is a discussion of potential strategies that will help to create and maintain an ethical environment thereby reducing moral distress such as facilitating dialogue, developing a support system, providing opportunities for professional development, and developing and revising institutional policies.     

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.     

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.     

The use of neonatal palliative care: Reducing moral distress in NICU nurses

The ethical dilemmas faced by nursing professionals can lead to moral distress and the abandonment of nursing as a career. This is especially true in intensive care nursing where mortality is more prevalent. Neonatal nurses face a particularly high rate of moral distress when dealing with the treatment and loss of critical infants. This distress is compounded when nurses feel that the care they are providing is not in the best interest of the infant. Providing palliative care at the end-of-life may alleviate some of this distress, but only if palliative care is implemented consistently and effectively. Several barriers exist to implementing effective palliative care. The primary barrier is the lack of education of neonatal staff in the correct definition and application of end-of-life comfort care. This includes education in communication, assessment of needs, and implementation. A neonatal-specific palliative care team (or individual palliative care nurse) can fill this gap in education to accommodate effective care. A consistent, effective neonatal palliative care program is essential. Such a program affords the opportunity for compassionate communication with the family, a decrease in moral distress for nurses, and the provision of quality end-of-life care for the neonate.     

Aged care nursing in Queensland - the nurses' view

Aims and objectives. Through comparison of two studies undertaken three years apart the opinions of nurses working in aged care facilities in Queensland were determined. Results will support policy planning for the Queensland Nurses Union. Background. An ageing population in Australia is placing increased demands on residential aged care facilities. In Queensland, the national situation is exacerbated by an influx of retirees from other states and territories. The ongoing problem of shortages of nurses in the workforce may be addressed by gaining further insight into the nurses’ own views of their conditions and experiences. Methods. One thousand nurses working in public and privately owned residential aged care facilities were surveyed by postal questionnaire in 2004. Results were compared with data collected in an identical study in 2001. Results. Respondents offered their opinions on working hours and conditions, professional development and experiences in nursing. The predominately female aged care nursing workforce is ageing. Reported workplace violence has increased substantially since 2001. Some improvements are reported in staff numbers, skill mix and workplace policies. Nurses expressed very serious concerns about pay, workload, stress, physical and emotional demands and staff morale. Conclusion. Working conditions for nurses in the residential aged care sector in Queensland must be addressed to retain the current nurses and to encourage new nurses to replace those that retire. Relevance to clinical practice. The findings of this study provide information not only for the Queensland Nurses Union but also policy makers and nurse managers both nationally and internationally on areas that need to be addressed to maintain the required workforce within the aged care sector.     

Nurses' moral sensitivity and hospital ethical climate: a literature review

Increased technological and pharmacological interventions in patient care when patient outcomes are uncertain have been linked to the escalation in moral and ethical dilemmas experienced by health care providers in acute care settings. Health care research has shown that facilities that are able to attract and retain nursing staff in a competitive environment and provide high quality care have the capacity for nurses to process and resolve moral and ethical dilemmas. This article reports on the findings of a systematic review of the empirical literature (1980 - February 2007) on the effects of unresolved moral distress and poor ethical climate on nurse turnover. Articles were sought to answer the review question: Does unresolved moral distress and a poor organizational ethical climate increase nurse turnover? Nine articles met the criteria of the review process. Although the prevailing sentiment was that poor ethical climate and moral distress caused staff turnover, definitive answers to the review question remain elusive because there are limited data that confidently support this statement.     

Conflict resolution strategies: when ethical dilemmas evolve into conflict

In critical care, ethical dilemmas arise when all duties, rights, and goals cannot be satisfied by the alternatives that are available. Conflicts evolve from ethical dilemmas due to differences in how nurses, physicians, administrators, and patients or families who are involved in a clinical situation assign priorities or interpret roles and responsibilities. This author presents strategies for critical care nurses to use to resolve conflicts that arise in relation to ethical dilemmas.     

Home care and hospice ethics: using the code for nurses as a guide

In today's rapidly changing healthcare environment, home care and hospice nurses face complex ethical dilemmas. Many result from situations with two opposing, but equally reasonable, solutions. Understanding how and why ethical dilemmas arise helps nurses recognize the potential for an ethical dilemma and formulate justifiable solutions. This article, the first of a new ethics column in Home Healthcare Nurse, sets the foundation for the nurse's understanding of these dilemmas by applying the American Nurses Association's Code for Nurses with Interpretive Statements to real case studies.