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.     

When the family asks, 'what happened?'

Because of the high level of acuity of hospitalized patients, untoward events can and do occur. Very often, nurses develop a caring relationship with the families of these patients. As a result, the family may approach the nurse about this negative turn of events. The questions that the family raises may create an ethical dilemma for the nurse. The nurse may wonder how to respond, feel powerless and "caught in the middle," and experience moral distress because of constraints in the health care system. This article discusses the ethical perspective of caring and the "nurse in the middle" phenomenon. Several strategies to help nurses manage this issue include consulting with a mentor, consulting with the institutional ethics committee, and promoting an ethical climate within the health care setting.     

Graduating nurses' self-efficacy in palliative care practice: An exploratory study

BackgroundEducational institutions and the health care industry agree that graduates from professional programs need to be “work ready” and capable of delivering competent and confident nursing care. One measure of program success is the student's self-efficacy in meeting expected graduate capabilities. In this study student's self-efficacy is related to palliative care graduate capabilities.AimTo explore graduating Bachelor of Nursing Science (BNSc) students' self-efficacy in caring for palliative care patients.DesignA qualitative design using semi-structured face-to-face interviews.SettingA regional Australian university.ParticipantsA purposive sample of 10 students in their final semester of study in a Bachelor of Nursing Science degree program.MethodSemi-structured face-to-face interviews were conducted. Interview questions were informed by published palliative care graduate capabilities. Interview data were transcribed verbatim and coded by capability. The coded data were then analysed to determine evidence of self-efficacy in caring for palliative care patients.ResultsAll participants had experiences in caring for palliative care patients. However, the responses did not consistently reflect high degrees of self-efficacy in four documented palliative care graduate capabilities required to care for persons with a life-limiting illness.ConclusionsThe findings support others that have identified gaps between curriculum and health care industry requirements in terms of students' beliefs about their empowerment to deliver nursing care as graduates. Education interventions and approaches to program evaluation require further development to better support students' growth of self-efficacy in undertaking their graduate roles.     

A cross-cultural comparison of nurses' ethical concerns

The aim of this study was to compare Swedish and Chinese nurses' experiences of ethical dilemmas and workplace distress in order to deepen understanding of the challenges neuroscience nurses encounter in different cultures. Qualitative interviews from two previously performed empirical studies in Sweden and China were the basis of this comparative study. Four common content areas were identified in both studies: ethical dilemmas, workplace distress, quality of nursing and managing distress. The themes formulated within each content area were compared and synthesized into novel constellations by means of aggregated concept analysis. Despite wide differences in the two health care systems, the nurse participants had similar experiences with regard to work stress and a demanding work situation. They were struggling with similar ethical dilemmas, which concerned seriously ill patients and the possibilities of providing good care. This indicates the importance of providing nurses with the tools to influence their own work situation and thereby reducing their work-related stress.     

Nursing, morality, and emotions: phase I and phase II clinical trials and patients with cancer.

This article reflects three nurses' views of the moral dimensions of their work in caring for patients receiving phases I and II of cancer clinical trials in a dedicated cancer clinical trials unit (CCTU). The nurses took part in a semistructured, tape-recorded, group interview in which they talked about any aspect of their work that they felt demonstrated its ethical or moral dimensions. The nurses were not employed as research nurses, but had chosen to specialize in cancer and palliative care in a CCTU environment. Three key themes emerged from the interview: being valued and moral distress; caring in a climate of scientific research; and care, cure, and consequences for moral reasoning. Working in an environment suffused with moral conflicts can be painful and damaging for the professionals involved. It would appear that if nurses are to function effectively, they need to be proactive in promoting an exploration of the role that emotions play in moral decision making and in examining the contribution of emotions to what they care about and why. A commitment to a shared understanding and valuing of divergent ethical reasoning in and across professional cultures of care and research paradigms also appears to be necessary. The terms "ethics" and "morals" are used interchangeably throughout this article.     

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.     

The ethics of refusing to care for patients during the coronavirus pandemic: A Chinese perspective

As a result of the coronavirus (COVID‐19) pandemic, health professionals are faced with situations they have not previously encountered and are being forced to make difficult ethical decisions. As the first group to experience challenges of caring for patients with coronavirus, Chinese nurses endure heartbreak and face stressful moral dilemmas. In this opinion piece, we examine three related critical questions: Whether society has the right to require health professionals to risk their lives caring for patients; whether health professionals have the right to refuse to care for patients during the coronavirus pandemic; and what obligations there are to protect health professionals? Value of care, community expectations, legal obligations, professional and codes of practice may compel health professionals to put themselves at risks in emergency situations. The bioethical principles of autonomy, justice, beneficence and non‐maleficence, as well as public health ethics, guide nurses to justify their decisions as to whether they are entitled to refuse to treat COVID‐19 patients during the pandemic. We hope that the open discussion would support the international society in addressing similar ethical challenges in their respective situations during this public health crisis.     

Improving Access to Health Care for Uninsured Elderly Patients

ABSTRACT The purpose of this article is to explore the barriers that the uninsured elderly population encounter when accessing health care in the United States. These barriers include, but are not limited to lack of transportation, insurance, or family support; the daunting complexity of the health care system; poverty; culture; poor patient‐health care provider communications; race/ethnicity; and lack of health care professionals such as nurses and doctors with adequate geriatric preparation, or generalists who are undereducated in geriatrics. The number of health care professionals currently available to treat elderly persons in the United States is inadequate. The Federal government should take steps to develop solutions to improve access to health care and decrease health disparities for older adults. As a nation, we should be proactive in addressing these concerns instead of waiting for new barriers to arise that further limit access to health care for elderly patients and their families. In this article, we provide an assessment of the barriers that limit access to health care in the uninsured elderly population and suggest recommendations and possible solutions to eliminate or reduce these barriers.     

Distress assessment: practice change through guideline implementation

Most nurses agree that incorporating evidence into practice is necessary to provide quality care, but barriers such as time, resources, and knowledge often interfere with the actual implementation of practice change. Published practice guidelines are one source to direct practice; this article focuses on the use of the National Comprehensive Cancer Network's Clinical Practice Guidelines for Oncology: Distress Management, which articulate standards and demonstrate assessment for psychosocial distress. Planning for the implementation of the guidelines in a feasibility pilot in a busy radiation oncology clinic is described. Results indicate that adding a distress assessment using the distress thermometer and problem checklist did not present substantial burden to nurses in the clinic or overwhelm the mental health, pastoral care, or oncology social work referral sources with more patients. Understanding distress scores and problems identified by patients helped the nurses direct education interventions and referrals appropriately; improved patient satisfaction scores reflected this.     

Emotional problems in primary care: what is the potential for increasing the role of nurses?

It has been suggested that the role of primary care and community nurses should be expanded in relation to mental health in order to assist in the prevention and management of prevalent emotional disorders such as depression and anxiety. However, relatively little is known about the mental health work presently undertaken by these nurses. Furthermore, nurses'training needs, attitudes and organizational barriers to role expansion in this area have not been systematically explored. This article seeks to review the literature on nurses' potential and current mental health work, current and future training needs, the views of patients and nurses concerning an expanded nursing role, and organizational issues of relevance. Educational interventions which have been systematically evaluated are also reviewed. The results suggest that nurses are already involved in emotional health care with a variety of patient groups, although this is not always acknowledged as mental health work. While clear potential for an expanded role exists, there is little consensus as to what role would be most effective for each nursing group, and few educational interventions have been demonstrated to be of proven effectiveness.     

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.     

Identifying Bioethics Learning Needs: A Survey of Canadian Emergency Medicine Residents

Objectives: Emergency medicine (EM) postgraduate training programs must prepare residents for the ethical challenges of clinical practice. Bioethics curricula have been developed for EM residents, but they are based on expert opinion rather than resident learning needs. Educational interventions based on identified learning needs are more effective at changing practice than interventions that are not. The goal of this study was to identify the bioethics learning needs of Canadian EM residents. Methods: A survey‐based needs assessment of Canadian EM residents was performed between July 2000 and June 2001. Residents were asked to identify their learning needs by rating bioethics topics and by relating their clinical experiences. Physicians and nurses who work with residents were surveyed in a similar manner and also asked to identify the residents' bioethics learning needs. Results: A total of 129 EM residents (77% of eligible residents), 94 physicians, and 87 nurses responded. Residents, physicians, and nurses all identified issues in end‐of‐life care as the greatest bioethics learning needs of the residents. Other areas identified as learning needs included negotiating consent, capacity assessment, truth telling, and breaking bad news. A learning need identified by nurses, but not residents, was the manner in which residents interact with patients and colleagues. Conclusions: This needs assessment provides valuable information about the ethical challenges EM residents encounter and the ethical issues they believe they have not been prepared to face. This information should be used to direct and shape ethics education interventions for EM residents.     

Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital

AIM: To determine the prevalence and contributing factors of moral distress in medical and surgical nurses. BACKGROUND: Moral distress from ethical conflicts in the work environment is associated with burnout and job turnovers in nurses. METHOD: A prospective cross-sectional survey using the Moral Distress Scale tool was administered to medical and surgical nurses at an adult acute tertiary care hospital. RESULTS: The survey was completed by 260 nurses (92% response rate). The intensity of moral distress was uniformly high to situations related to physician practice, nursing practice, institutional factors, futile care, deception and euthanasia. Encounter frequencies for situations associated with futile care and deceptions were particularly high. Encounter frequencies increased with years of nursing experience and caring for oncology and transplant patients. CONCLUSION: Moral distress is common among nurses in acute medical and surgical units and can be elicited from different types of situations encountered in the work environment. Nursing experience exacerbated the intensity and frequency of moral distress. IMPLICATIONS FOR NURSING MANAGEMENT: Strategies aimed to minimize exposure to situations of moral distress and augment mechanisms mitigating its effect on nurses are necessary to enhance job satisfaction and retention.     

Healthy eating and physical activity among new graduate nurses: A qualitative study of barriers and enablers during their first year of clinical practice

BackgroundNew graduate nurses entering the workforce experience numerous barriers to maintaining a healthy lifestyle including shift work, the high cost of healthy foods at the workplace and high levels of exhaustion which reduce motivation to participate in regular physical activity. Research has documented unhealthy lifestyles among nurses across the profession. However, few studies focus on graduates' experiences during their transition into their careers.AimTo investigate the barriers and enablers to healthy eating and participation in physical activity for new graduate nurses during their first year of clinical practice, and to explore attitudes to participation in workplace health promotion programs.MethodsSemi-structured interviews informed by the socioecological model were conducted with 24 new graduate nurses and analysed using thematic analysis.FindingsFour key themes emerged as barriers to healthy eating and physical activity: time, shift work, work environment, and work culture. Participants indicated a high interest in workplace health promotion programs.DiscussionLimited time and shift work impact on the eating and physical activity behaviours of new graduate nurses which leads to unhealthy snacking to maintain energy, as does high levels of exhaustion, reduced motivation to eat healthy foods, and decreased participation in physical activity. The work culture and environment also influence eating behaviours. Inadequate breaks lead to consumption of foods that are quick to eat but often low in nutrients.ConclusionNew graduate nurses experience the same difficulties in maintaining healthy lifestyles as more experienced nurses. Understanding the barriers which influence their dietary and physical activity behaviours can help inform strategies to improve the health of nurses at a critical time when they enter the nursing workforce.     

The use of reflective practice in new graduate registered nurses residency program

New graduate nurses encounter emotional distress related to complex patient care situations and overwhelming workloads. Unequipped with coping mechanisms, new nurses verbalize difficulty feeling accepted in their assigned units. Self-perceptions of inadequacy and lack of independence contribute to anxiety. Consequently, hospitals are at risk for losing newly graduated nurses within the first year. The cost of losing new nurses is overwhelming to hospital institutions and further contributes to the looming nursing shortage. This article describes the use of a reflective practice exercise in a new registered nurse residency program in a magnet hospital to facilitate reflection and problem solving in the patient care unit. More research is needed to investigate the effectiveness of reflective practice in developing coping skills and retention rate in new graduate nurses.     

From private to public: negotiating professional and personal identities in spiritual care

AIM: This paper is an exploration of the challenge of negotiating the highly personalized concept of spirituality within the public sphere of professional-patient interactions. BACKGROUND: Spirituality has become increasingly prominent within the nursing discourse, and providing spiritual care is often positioned as an ethical obligation of care. However, bringing such a personal concept into the public domain of care creates some unique tensions and ethical risks. DISCUSSION: Nurses bring three potentially competing identities to spiritual care encounters with patients. Firstly, they are professionals with a public trust in health promotion and restoration, including those areas that intersect with spiritual health. Secondly, they are citizens of a liberal society where non-judgmental pluralism as it relates to spirituality is enshrined. Thirdly, they are individuals who hold particular beliefs and values about spirituality. Each of these identities may result in particular, and potentially conflicting, approaches to spiritual care. Ultimately, the identity which nurses choose to adopt is often determined by how they view themselves in the spiritual care encounter, either as experts with legitimate authority to intervene in the spiritual lives of patients or as people in a shared relational encounter. Each of these approaches carries ethical risks, although the nature of these risks is different. CONCLUSION: The identities which nurses bring to spiritual care encounters have far-reaching implications for patient experiences in those encounters. Nurses who position themselves as experts run the risk of objectifying the spiritual, being experienced as coercive and transcending nursings' competence. The work of Martin Buber is presented as a model that, while acknowledging competing identities, sets forth a vision of spirituality and spiritual care based upon relational reciprocity.     

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.     

Immigrants in emergency care: Swedish health care staff's experiences

BACKGROUND: During the past few decades Sweden has developed into a multicultural society. The proportion of patients with different cultural backgrounds increases, which naturally makes new demands on health care staff. AIM: To identify whether staff in somatic and psychiatric emergency care experienced problems in the care of migrants, and if so to compare these. METHOD: The study design was explorative. Focus group interviews of 22 women and 13 men working as nurses and assistant nurses at an emergency ward, an ambulance service and a psychiatric intensive care unit were held. FINDINGS: The results showed that the main problems experienced in all wards were difficulties related to caring for asylum-seeking refugees. Some dissimilarities were revealed: unexpected behaviours in migrants related to cultural differences described by staff working in the emergency ward; migrants' refusal to eat and drink and their inactive behaviour in the psychiatric ward; and a lot of non-emergency runs by the ambulance staff because of language barriers between the emergency services centre and migrants. CONCLUSION: The main problems experienced by the health care staff were situations in which they were confronted with the need to care for asylum-seeking refugees. PRACTICE IMPLICATIONS: These emphasize the importance of support from organizational structures and national policies to develop models for caring for asylum-seeking refugees. Simple routines and facilities to communicate with foreign-language-speaking migrants need to be developed. Health care staff need a deeper understanding of individual needs in the light of migrational and cultural background.     

Preserving moral integrity: a follow-up study with new graduate nurses

Preserving moral integrity: a follow-up study with new graduate nurses ¶The purpose of this follow-up study was to describe, explain and interpret how new graduate nurses perceived their adaptation to the ‘real world’ of hospital nursing and what they perceived as major influences on their moral values and ethical roles in the 2 years following graduation. The method was qualitative, specifically grounded theory. The earlier study took place when informants were senior nursing students. The follow-up study began after the informants had been practising for 1 year. Research questions guiding the study were: How do new graduate nurses describe their adaptation to the ‘real world’ of hospital nursing? What do they describe as factors influencing their moral values and ethical roles in hospital nursing? Preserving moral integrity was the basic psycho-social process that explained how these new graduate nurses adapted to the real world of hospital nursing. Six stages of this process were identified: vulnerability; getting through the day; coping with moral distress; alienation from self; coping with lost ideals; and integration of new professional self-concept. Moral distress was a consequence of the effort to preserve moral integrity. It is the result of believing that one is not living up to one’s moral convictions. Data supported that the most pervasive attributes of moral distress were self-criticism and self-blame, as informants judged their actions against their moral convictions and their standards of what a good nurse would do. Moral distress was an acute form of psychological disorientation in which informants questioned their professional knowledge, what kind of nurses they were and what kind of nurses they were becoming. Theoretical explanations of these findings are grounded in social interaction and moral psychology theories.