Iranian intensive care unit nurses' moral distress: a content analysis

Researchers have identified the phenomena of moral distress through many studies in Western countries. This research reports the first study of moral distress in Iran. Because of the differences in cultural values and nursing education, nurses working in intensive care units may experience moral distress differently than reported in previous studies. This research used a qualitative method involving semistructured and in-depth interviews of a purposive sample of 31 (28 clinical nurses and 3 nurse educators) individuals to identify the types of moral distress among clinical nurses and nurse educators working in 12 cities in Iran. A content analysis of the data produced four themes to describe the nurses' moral distress. The four themes were as follows: (a) institutional barriers and constraints; (b) communication problems; (c) futile actions, malpractice, and medical/care errors; (d) inappropriate responsibilities, resources, and competencies. The results demonstrate that moral distress for intensive care unit nurses is different and that the nursing leaders must reduce moral distress among nursing in intensive care.     

Nurses' experiences of research utilization within the framework of an educational programme

This paper explores nurses' reflections on their experiences of disseminating and implementing research findings in clinical practice within the framework of an educational programme. Ten registered nurses, all in clinical practice, participated in a research-orientated educational programme with the aim of facilitating the dissemination and implementation of research findings in clinical practice. Thus, the programme contained different activities designed to disseminate and implement research findings in the participants' wards. Focus groups were used to collect data and a qualitative content analysis was performed. The main themes that were developed were: organizational and leadership issues; acquiring a new role; responses and reactions by others; and orientation to research. Organizational and leadership issues, nurses' interest in research, nurses' reading habits, and support and feedback from their head nurses and other managers and from their nursing colleagues and physicians were seen as important. This study confirms that research utilization and the change to research-based nursing practice are complex issues which require both organizational and educational efforts.     

A discursive exploration of the practices that shape and discipline nurses' responses to postoperative delirium

A discursive exploration of the practices that shape and discipline nurses' responses to postoperative delirium Although delirium is classified as a medical emergency, it is often not treated as such by health care providers. The aim of this study was to critically examine, through a poststructural, Foucauldian concept of discourse, the language practices and discourses that shape and discipline nurses' care of older adults with postoperative delirium (POD) with a purpose to question accepted nursing practice. The study was based on data collected from face-to-face, in-depth, personal interviews with six nurses who work on an acute postoperative patient care unit. Five analytic readings of the data identified two prominent discourses at work in nursing practice which influenced the care of patients with POD. These were identified as discourses of legitimacy/illegitimacy and discourses of nursing work. Through the process of poststructural analysis it became evident that one overriding discourse - the biomedical/scientific discourse - served to direct, legitimize and govern all other discourses. The findings of this study have implications for nursing knowledge and practice, length of hospital stay and improved patient outcomes. This study builds on previous work and is the first study to conduct a discourse analysis illuminating nurses' responses to POD through comparison with other acute medical emergencies from a poststructural perspective.     

Antecedents of Severe and Nonsevere Medication Errors

Purpose: To investigate if differences in antecedents of severe and nonsevere medication errors exist.
Design: A longitudinal study of 6 months of data from 279 nursing units in 146 randomly selected hospitals in the United States (US).
Methods: Antecedents of severe and nonsevere medication errors included work environment factors (work dynamics and RN hours), team factors (communication with physicians and nurses' expertise), person factors (nurses' education and experience), patient factors (age, health status, and previous hospitalization), and medication-related support services. Generalized estimating equations with a negative binomial distribution were used with nursing units as the unit of analysis.
Findings: None of the antecedents allowed predicting both types of medication errors. Nurses' expertise had a negative and medication-related support services had a positive association with nonsevere medication errors. Nurses' educational level had a significant nonlinear relationship with severe medication errors only: As the percentage of unit BSN-prepared nurses increased, severe medication errors decreased until the percentage of BSN-prepared nurses reached 54%. In contrast, RN experience had a statistically significant relationship with nonsevere medication errors only and nursing units with more experienced nurses reported more nonsevere medication errors.
Conclusions: Severe and nonsevere medication errors might have different antecedents.
Clinical Relevance: Error prevention and management strategies should be targeted to specific types of medication errors for best results.     

Discourses on empowerment.

The discourse community of British psychiatric and mental health nursing is a contested realm. The 'Big Stories' of policy and planning of services are clearly articulated in disputes in journals, but the 'Little Stories' of nurses' work and patients' or users' experiences may be ignored or under-valued. This paper illustrates how the Big Story of a central theme in current policy--empowerment--is articulated in the realm of research funding and design, and how it is articulated by practitioners. The paper focuses attention on the responsibilities faced by researchers, in relating the Little Stories of practice and the Big Story of policy. It reports early and tentative findings from a study of community psychiatric nurses' empowerment of people with enduring mental disorders. The paper suggests ways in which strategies for analysis of qualitative data from interviews with CPNs may be informed by ideas drawn from the field of discourse analysis; reflexively examining how researchers' discourses relate to those of policy makers and mental health nursing practitioners. This paper is based on a presentation at the Network for Psychiatric Nursing Research Conference, Napier University, Edinburgh, 17 September 1997.     

Emotional intelligence in mental health nurses talking about practice

The aim of this study was to explore mental health nurses' experiences of emotional intelligence (EI) in their nursing practice by means of qualitative interviews. The interview questions where developed from the literature on EI. This study used a hermeneutic analysis. Four main themes emerged: relationship with the patient; the substance of supervision; motivation; and responsibility. It was concluded that EI stimulates the search for a deeper understanding of a professional mental health nursing identity. Emotional learning and maturation processes are central to professional competence, that is, personal growth and development. In addition, the moral character of the mental health nurse in relation to clinical practice is of importance. The findings imply multiple types of intelligence related to nursing science as well as further research possibilities within the area of EI.     

The first nurse-patient encounter in a psychiatric setting: discovering a moral commitment in nursing

The aim of this study was to deepen nurses' understanding of the importance of carefully managing the first nurse-patient encounter in a psychiatric setting according to each patient's suffering and future hopes. The study was carried out using an action research approach. The action planned was the implementation of a conceptual model reflecting Eriksson's caring theory. Data were collected by interviews with nurses and observational notes kept in a research diary. The data analysis followed the procedure of qualitative content analysis. A generalization of the entire learning process shows the first nurse-patient encounter to be a moral commitment in nursing. A theoretical framework of nursing assessment conveying knowledge about the patient as unique and being a whole person can support the nurse in encouraging the patient to enter into a relationship. This insight stimulated the nurses in this study to reflect on the moral responsibility of continuing the relationship and initiating an ongoing nursing process. Awareness of this responsibility made them reflect more on the possibility of nurses taking autonomous actions in order not to abandon the patient and to avoid feeling guilty.     

A comparative analysis of contemporary nurses' discontents

AIM: This paper reports a study to evaluate and increase understanding of contemporary Registered Nurses' discontents, and to compare these discontents and their effects with those of nurses 20 years ago. BACKGROUND: In 1986, Turner argued that nurses' discontents were reflected in a discourse or 'vocabulary of complaint' that provided a sense of solidarity amongst practising nurses, and defused their frustrations rather than channelling them into demands for workplace reform. In this paper, we revisit Turner's notion of a vocabulary of complaint in the context of a study of nurse retention in the contemporary Australian healthcare workplace. METHODS: This paper draws on the qualitative data from a larger project (completed in 2001) exploring the relationship between job satisfaction and self-concept in both recently graduated and experienced nurses. Here, we elaborate on thematic analyses of the comments of 146 Australian Registered Nurses with more than 5 years' nursing experience. FINDINGS: There is still a high level of discontent amongst contemporary practising nurses, although the focus of their complaints and their responses to them have changed since Turner's study. Conflicting expectations of nurses and managers and lack of opportunity to provide comprehensive care emerged as the most important issues for experienced nurses today. Rather than contributing to a sense of solidarity as in Turner's study, contemporary nurses' discontents reflect intense personal frustration and underpin individual nurses' decisions to leave, or plan to leave, the workforce. CONCLUSION: There is an urgent need for increasing health service management and community awareness about the relationship between providing comprehensive nursing care and nurses' job satisfaction. Addressing nurses' discontents, wider nursing involvement in the international policy arena, and the politicization of nurses worldwide may contribute to alleviating the current global nursing shortage.     

Is there a unique nursing ethic?

There is no agreement in the nursing literature as to the meaning of the term, nursing ethics. Proposed definitions refer to nurses' moral decision-making and behaviors, ethical conflicts, and analysis of ethical issues that arise within nurses' practice. Presumably, a distinct nursing ethic should address unique theories, standards, and inquiry into what comprises nurses' ethical behavior and study of how nurses actually behave and reason about ethical issues. The purpose of this column is to synthesize the dialogue regarding the potential existence of a unique nursing ethic, and to propose that such an ethic has yet to emerge.     

Why are nurses leaving nursing?

The causes of nurses' exodus from acute health care delivery practice may lie more in intrinsic factors rather than the heretofore overtly expressed reasons. This article examines bureaucratic factors, issues related to the medical profession and medical/scientific discourse, and factors within the nursing profession itself that may contribute to a nurse's unhappiness and dissatisfaction that causes him or her to leave. Nursing as emotional work and the implications for the individual nurse, and nursing as moral and moral distress are discussed. Suggestions to facilitate retention are made for changing the work environment to feel valued for their skillfully applied humanness.     

Delirium and older people: repositioning nursing care

Aims. To critically examine the nursing care offered to older people who have been delirious. Background. Delirium occurs as a result of physiological imbalances resulting in an alteration in consciousness and cognitive impairment. Delirium is a prevalent and serious cognitive disorder experienced by older people. While there is a vast number of studies published utilizing quantitative methods, there remains a dearth of research relating to delirium in older people from a qualitative perspective. Design. A qualitative research design that utilized a critical gerontological framework underpinned this study. This framework drew on aspects of postmodernism and Foucault's understanding of discourse. Methods. Data sources included published documents on delirium, semi‐structured taped interviews with people over the age of 65 years who had been delirious (as well as their clinical notes), family members, Registered Nurses and a hospital doctor. A postmodern discourse analytic approach was used to interrogate the 20 sets of data collected. Findings. Textual analysis revealed the presence of two major discourses impacting on being an older person with delirium. These were identified as a nursing discourse of delirium and a personal discourse of delirium. A nursing discourse of delirium was largely focussed on the biomedical processes that resulted in a delirious episode. Conversely, a personal discourse of delirium highlights that there are other ways of ‘knowing’ about delirium through considering the narratives of older adults, and their families, when offering a nursing service to this group of people. Relevance to clinical practice. Nursing needs to critically examine all aspects of nursing care as it applies to older people who have delirium to ensure the rhetorical claims of the profession become the reality for consumers of health services. The use of critical gerontology provides nurses with the tools to challenge the status quo and uncover the multiple, varied, contradictory and complex representations of delirium in older people. Inherent within a personal discourse of delirium is the importance of incorporating into nursing care communicative and other relational activities, such as forming and maintaining a therapeutic relationship.     

Nurses' motivations for studying third level post-registration nursing programmes and the effects of studying on their personal and work lives

Internationally nurses' motivations for post-registration education and the effects of studying are important concerns for the profession. This paper describes Irish nurses' motivations for studying post-registration nursing programmes and the effects of studying on their personal and work lives. Eighteen nurses participated in this qualitative study. Data were collected using three focus groups and a one-to-one interview. Data were analysed using the qualitative data analysis method Framework [Ritchie, J., Spencer, L., 1994. Qualitative data analysis for applied policy research. In: Bryman, A., Burgess, R. (Eds.), Analyzing Qualitative Data. Routledge, London, pp. 173-194]. Three themes were identified: "I want to keep up and I want to keep in there," "It's about juggling and getting the balance" and "I'm looking at things differently." Findings revealed that nurses studied to aid their professional development. Contextual factors influenced their motivations including a free fees initiative and Irish nursing developing into an all graduate profession. The impact of studying on their personal and work lives was broader in scope than their motivations.     

Nurses' codes of ethics in practice and education: a review of the literature

The purpose of this review was to provide an overview of the empirical literature on nurses' codes of ethics in practice and education covering the time from 1980 to August 2007. The focus was on methodological issues, main domains of interest and findings of the studies. The aim of the review was to identify knowledge gaps and to provide recommendations for further research. Research on the codes of ethics in nursing is scarce. The main domains of interest were education, nurses' knowledge and use of the codes, the content and functions of the codes, and moral behaviour and values related to the codes. Education of the codes was important, and it had a positive impact on students' moral behaviour measured by an instrument based on the codes. Nurses' knowledge and use of the codes was deficient. Nurses' practice was guided by environmental contexts and personal experiences rather than the codes. However, nurses' values espoused those of the codes. The nurse–patient relationship was the best known aspect of the codes. Methodological diversity, a small number of studies focusing on several domains of interest warrants care in the interpretation of the findings. Further research should focus particularly on the education of the codes, covering the realization of the teaching process, evaluation of outcomes and organization of education. Cooperation between theoretical education and clinical practice should be explored. Research of the meaning of the codes and their functions for nurses, nurses' moral behaviour and professional values is needed. Research should cover all levels and areas of nursing and reach beyond the nurse–patient relationship to relationships with colleagues, other health professions, organizations and the society. The use of more varied methodological approaches is suggested.     

The experiences of the registered nurse caring for the person dying of cancer in a nursing home

This paper reports on research that set out to identify and describe the experiences of the registered nurse caring for the resident dying of cancer in a nursing home. The research method used was a qualitative single case study involving five registered nurses in one nursing home. Thematic analysis of data from unstructured interviews and reflective journals was used to explicate the nurses' experiences. Four major themes were extracted from the data. These themes were the exclusivity of the relationships, difficulties in the management of pain, the expectations of the registered nurse and the impact of caring. The nurses' experiences were loving, fascinating, compelling and rich. The overarching experience of the nurses came from the relationship they formed with the residents. A crucial finding in this study was that these registered nurses valued the elderly resident and developed meaningful relationships with them. All aspects of the relationships were unique and profound. However, the emotional involvement with the resident, multiple death losses, confrontation of personal losses, limited workplace support such as counselling, potentially places these registered nurses at emotional risk from burnout and complicated bereavement. The implications of these findings for nursing practice, education and research are discussed.     

Understanding the cognitive work of nursing in the acute care environment

OBJECTIVE: To combine human factors engineering techniques with qualitative observation of nurses in practice to analyze the nature of nurses' cognitive work and how environmental factors create disruptions that pose risks for medical errors. BACKGROUND: Few researchers have examined the nature of nurses' cognitive work while in practice with patients. Researchers have described the broad range of thinking processes required in the acute care work setting, but have failed to examine how such processes are conducted and influenced by the complex care environment. A combined research methodology enables researchers to better understand how the nursing process becomes disrupted and the potential influence of this disruption on the safe and effective care of patients. METHODS: An ethnographic study, using mixed-methodological approaches, involved 7 staff registered nurses. The quantitative and qualitative data collection included field observation and summarative interviews. FINDINGS: A high number of cognitive shifts and interruptions, and a nurse's cumulative cognitive load, create the potential for disrupting a nurse's attention focus during care of patients. A majority of interruptions occurred as nurses performed interventions, particularly medication preparation. CONCLUSION: New attention must be given to how care systems and work processes complement or interfere with nurses' cognitive work.     

Acute care nurses'' experiences of moral certainty

Moral certainty is a common, vivid experience for many nurses, but it may be a mixed blessing. From one perspective moral certainty provides comfort for the ethical decision-maker and may prompt necessary action which would have been impossible without it. From another perspective, moral certainty stifles dialogue and in-depth discussion of moral issues. Despite the fact that moral certainty is ubiquitous in health care, few research studies have explored both the positive and negative aspects of this complex and sometimes troubling concept. A qualitative design was used to describe the experiences of 20 acute care nurses with moral certainty. They were interviewed and the interviews analysed using Colaizzi's method for qualitative data analysis. These nurses' primary responses to moral certainty were 'speaking up', 'standing up' and 'refusing to participate'. Their experiences with moral certainty, responses to it, reasons for responding as they did, and clinical prompts are described. The author concluded that moral certainty may have positive and negative aspects. Making an effort to hear alternative views is suggested.     

Developing a questionnaire to measure nurses' attitudes towards hospitalized older people

A number of studies have used generic measures to evaluate nurses' attitudes toward hospitalized older people. Those measures do not consider the context in which nurses meet older people and the influence that this may have on nurses' attitudes. The aims and objectives of the study were to develop a questionnaire from focus group data to evaluate nurses' attitudes towards hospitalized older people. To evaluate the psychometric properties of the questionnaire the design included a qualitative and quantitative phase. The method used for the qualitative phase was focus group interviews with the intention of identifying the phenomena that may indicate nurses' attitudes towards older people. The quantitative phase included the development and psychometric testing of an attitudinal questionnaire. Samples for the qualitative phase included Registered Nurses from the care of older people setting; Registered Nurses from the acute setting; nursing students and nurse teachers. The sample for the quantitative phase included nursing students (numbering 355). Ten themes were identified through thematic analysis. Eighty items were extrapolated from the qualitative analysis and used to formulate a questionnaire which was then distributed to the nursing students. On analysis, the reliability was 0.78. Further analysis using Principal Components Analysis (P.C.A.) with orthogonal rotation indicated that 45 items loaded on to eight factors. Results of the quantitative analysis indicated that there was a strong correlation between the thematic analysis and the P.C.A. The results would suggest that there may be important and relevant domains that are worthy of further study into nurses' attitudes towards older people. If the domains identified are useful for identifying negative attitudes towards older people, then strategies can be implemented to try and reduce negative attitudes in clinical practice.