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.     

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.     

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.     

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.     

Values that matter, barriers that interfere: the struggle of Canadian nurses to enact their values.

Qualitative interviews were conducted with 20 nurses in a Canadian city to explore the moral experience of nurses in their working lives. The participants were asked what they valued in their profession and how well their work lives enabled them act on their values. Almost uniformly, they expressed commitment to the values of helping others, caring, making a difference, patient-centredness, advocacy, professional integrity, holistic care, and sharing knowledge for patient empowerment. They identified several challenges and frustrations experienced in attempting to enact these values. System-level challenges included professional hierarchies, organizational structures, issues in the health-care system, and power dynamics. Removing these barriers cannot be left to nurses alone. It requires complex, wide-ranging strategies: system change, power restructuring, and the creation of ethical climates and cultures that support values that are essential to good patient care.     

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.     

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.     

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.     

How professional nurses working in hospital environments experience moral distress: a systematic review

The experience of moral distress for professional nurses working in hospital environments causes a myriad of biological, psychological, and stress-related reactions. There is an institutional culpability in producing an environment where moral distress is experienced. This is particularly true when nurses feel the need to advocate for patients' well-being while coping with institutional constraints. The perception of patient pain and suffering as a result of medical decisions, which the nurse has little power to influence, contributes to the experience. Unequal power structures, prevalent in institutions, exacerbate the problem. Critical care nurses need to recognize moral distress and its adverse impact on providing optimal patient care. Critical care nurses should make a personal commitment that moral distress will not impact their nursing care and take a leadership role in their units to address this issue with their employing institution and develop strategies to lessen the impact of moral distress. These strategies should be based on the best available evidence such as this systematic review and other relevant appraised works.     

Registered Nurses' personal rights vs. professional responsibility in caring for members of underserved and disenfranchised populations

Aims. Health disparities exist and refer to the chasms in health status between the advantaged and disadvantaged. Intense multiculturalism will require different approaches and moral obligations to work with these groups and urgency exists to develop nursing caring strategies when dealing with these populations. Development of nursing curricula which identify prejudicial thinking and intolerance for marginalized groups will help to decrease fears and increase nurses’ willingness to provide culturally competent health care for underserved and disenfranchised populations. Background. Caring for members of disenfranchised groups instills fear at some level in nurses who are working with these individuals. This fear may be due, in part, to the potential harm nurses perceive the patient may cause them, or perhaps it is because they feel they could possibly be in the individual's situation at some point in their lives. Prejudice and discrimination continue to exist in society and have adversely affected the health care system and the nursing profession. Discrimination may be based on differences due to age, ability, gender, race, ethnicity, religion, sexual orientation, or any characteristics by which people differ. Relevance to clinical practice. Registered Nurses are accountable for nursing decisions and actions regardless of personal preferences. Due to the rapidly changing healthcare system the nurse faces increasing ethical dilemmas and human rights issues. Nurses are individually accountable for caring for each patient and the right to refuse an assignment should be carefully interpreted to avoid patient abandonment. Nurses’ objections can be based on moral, ethical, or religious beliefs not on personal preferences and in an emergency the nurse must provide treatment regardless of any personal objections.     

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.     

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.     

Compassion practice by Ugandan nurses who provide HIV care

Compassion is fundamental to ethical nursing practice; it represents a commitment to acknowledge and respond to the suffering of the patient. Many structural, economic, and sociopolitical challenges confront Ugandan nurses in their efforts to incorporate compassion into their care of persons with HIV illness. After reviewing the literature related to compassion fatigue, the author describes nursing in sub-Saharan Africa and presents a qualitative study exploring the impact of education on 24 nurses' lives, including their capacity to avoid or mitigate the development of compassion fatigue. Data were collected through interviews, observation, and focus group discussions. Findings illustrate the barriers participants faced in providing competent care and the liberating effects of new knowledge and skills. Engaging in meaningful relationships, maintaining hopeful attitudes, and advocating for the profession were found to transform and affirm the nurses' approach toward their work and enhance their experiences of compassion satisfaction. The author discusses the unique aspects of the experience of compassion among Ugandan nurses caring for persons with HIV illness.     

Nursing ethics in a developing country

Nursing is a true profession, distinguished by its philosophy of care, its full-time commitment to human wellbeing, its particular blend of knowledge and skills and its valuable service to the community (Curtin & Flaherty, 1982:92). Ethics is vital to nursing. Being a professional implies ethical behaviour and knowledge of what it means to be ethical (Pera & Van Tonder, 1996:v). Ethics is the foundation of committed service to humankind. When nurses practice is an ethical manner they should adhere to ethical principles like autonomy, beneficence, justice, veracity, fidelity, confidentiality and privacy. From this conceptual framework two questions can be asked, namely: Does the behaviour of nurses in health services in South Africa comply with the principles of ethics? How can ethical behaviour be facilitated in nurses in South Africa? The first question was answered by doing a critical analysis of thirty-two case studies of recent ethical phenomena in health services. The ethical principles will be used as criteria for this analysis. Some of the ethical case studies will be presented in this paper to indicate the problems in relation to autonomy, beneficence, justice, veracity and fidelity. It will be demonstrated that from deontological ethical theories nurses are not doing their duty as advocates for the vulnerable patient and from utilitarianism the poor and uneducated patients are being exploited. To empower patients in developing countries it is of vital importance for nurses to behave in an ethical manner. From a literature study a program for rational interaction for moral sensitivity (Rossouw, 1995) and virtue-based ethics in Nursing Education is identified to facilitate moral behaviour amongst nurses in developing countries.     

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.     

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.     

Aging, experienced nurses: their value and needs

The nursing workforce mirrors the trend in population; that is, it is aging. Subsequently, older nurses experiencing some aging effects themselves are caring for more elderly patients needing more assistance with illness and wellness problems. To meet the growing demand for care in this era of nursing shortage, predicted to last beyond 2020, these nurses are needed to remain in the workforce longer. Lack of nurses in the workplace compromises patient care and increases job stress. Therefore, retention incentives need to be implemented to assist aging, experienced nurses to delay retirement or prevent them from leaving the profession early, as well as encouraging younger and future nurses to work longer. This article focuses on aging nurses, describing their demographics and needs, explicating their value and listing the resources and benefits needed to prolong their vital services in the workforce. (For this article, aging, older and mature refer to experienced nurses in their 40s, 50s and 60s.).     

Caring, patient autonomy and the stigma of paternalism

Caring, patient autonomy and the stigma of paternalism ¶This paper utilizes data generated during a qualitative study in palliative and maternity care settings to guide discussion of the current discourse, which emphasizes patient autonomy and derides paternalism. Data are presented which illustrate that this ideology is established in nursing practice. Respect for patient autonomy is identified as an essential element of individualized, patient-centred and ethical care but conversely, it is suggested that over-emphasis may confuse and suppress beneficent intervention. The value of ethical theory to provide an objective means to explore ethical dilemmas in practice is not debated, but exploration of the issues raised by the data suggest, that principle-based ethical theory suffers the following constraints: the predetermined balance of ethical principles in favour of respect for autonomy prevents an unbiased perspective and optimum guidance; in contrast to caring relationship, application of ethical theory does not reveal the particulars necessary to guide ethical decisions aimed at promoting good for the individual; current discourse appears to disregard the inherent inequality in the relationship between the helped and helper and practitioners' need to preserve their own moral integrity. Consequently, this paper argues that beneficence derived through caring should not be superseded uncritically and suggests that mutual nurse-patient relationship, which balances respect for patient autonomy and beneficent guidance based on practitioner's clinical expertise, protects the moral integrity of both patient and practitioner. For conciseness, the term patient will be used to indicate recipients of both nursing and midwifery care and while both nurses and midwives are not always specified, any term referring to nurses, denotes both.