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Encountering ethical problems and moral distress as a nurse: Experiences, contributing factors and handling
Jönköping University, School of Health Science.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aim of this thesis was to explore and describe what nurses find ethically problematic and morally distressing in their work, the factors contributing to the arising of ethically problematic situations and the actions reported taken in order to handle them, thus creating an ethical climate.

Descriptive as well as correlational and exploratory designs were employed in the four papers on which this thesis is based. A total of 283 nurses from 21 acute care wards at four Swedish hospitals participated. Interviews were analyzed using qualitative content analysis and the critical incident technique, and questionnaires were analyzed using descriptive and non-parametric statistics.

The nurses described ethical problems and moral distress related to decision making about life-sustaining treatment, but also when they experienced difficulties in preserving a patient’s integrity and when they could not give care that was necessary and safe. Inadequate communication between healthcare staff, the physicians’ ways of handling potentially ethically problematic situations and patients’ poor state of health, which hindered their participation in decisions concerning them, were some of the factors that could contribute to the rise of an ethically problematic situation. Among the actions described as being used to handle ethical problems and moral distress, some were explicitly stated to promote a positive ethical climate, i.e. a perceived positive handling of ethical issues. These were supporting each other in the working group, using policies and routines as help, giving care based on the needs of patients and their next of kin and daring to speak out, thus contributing to setting a standard for behavior. Having the need for explanations and information satisfied and working as a team also promoted a positive ethical climate.

In conclusion, the professional role of being a nurse seems to be of importance not only when it comes to what situations are experienced as ethically problematic and morally distressing, but also concerning what factors may contribute to the rise of them. Perceiving a positive ethical climate may mediate these experiences.

Place, publisher, year, edition, pages
School of Health Sciences, Jönköping University , 2011. , 67 p.
Series
Hälsohögskolans avhandlingsserie, ISSN 1654-3602 ; 20
National Category
Nursing
Identifiers
URN: urn:nbn:se:hj:diva-16429ISBN: 978-91-85835-19-5 (print)OAI: oai:DiVA.org:hj-16429DiVA: diva2:450421
Public defence
2011-11-11, Forum Humanum, Hälsohögskolan, Jönkping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-10-21 Created: 2011-10-20 Last updated: 2014-05-20Bibliographically approved
List of papers
1. Workplace Distress and Ethical Dilemmas in Neuroscience Nursing
Open this publication in new window or tab >>Workplace Distress and Ethical Dilemmas in Neuroscience Nursing
2008 (English)In: Journal of Neuroscience Nursing, ISSN 0888-0395, Vol. 40, no 4, 222-231 p.Article in journal (Refereed) Published
Abstract [en]

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.

Keyword
Swedish nurses, workplace stress, ethical dilemma, coping, quality of nursing, content analysis
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-6789 (URN)
Available from: 2008-12-04 Created: 2008-11-11 Last updated: 2011-10-21Bibliographically approved
2. Nurses' conceptions of decision making concerning life-sustaining treatment
Open this publication in new window or tab >>Nurses' conceptions of decision making concerning life-sustaining treatment
2008 (English)In: Nursing Ethics, ISSN 0969-7330, Vol. 15, no 2, 160-173 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to describe nurses' conceptions of decision making with regard to life-sustaining treatment for dialysis patients. Semistructured interviews were conducted with 13 nurses caring for such patients at three hospitals. The interview material was subjected to qualitative content analysis. The nurses saw decision making as being characterized by uncertainty and by lack of communication and collaboration among all concerned. They described different ways of handling decision making, as well as insufficiency of physician-nurse collaboration, lack of confidence in physicians, hindrances to patient participation, and ambivalence about the role of patients' next of kin. Future research should test models for facilitating communication and decision making so that decisions will emerge from collaboration of all concerned. Nurses' role in decision making also needs to be discussed.

Keyword
Adaptation; Psychological, Adult, Attitude of Health Personnel, Communication Barriers, Conflict (Psychology), Cooperative Behavior, Decision Making/ethics, Family/psychology, Humans, Life Support Care/ethics/*psychology, Nursing, Nurse's Role/psychology, Nursing Methodology Research, Nursing Staff; Hospital/ethics/*psychology, Patient Advocacy, Ethics, Patient Participation, Physician-Nurse Relations, Power (Psychology), Qualitative Research, Sweden, Uncertainty
National Category
Nursing Nursing
Identifiers
urn:nbn:se:hj:diva-5679 (URN)18272607 (PubMedID)
Available from: 2008-06-10 Created: 2008-06-10 Last updated: 2011-10-21Bibliographically approved
3. Moral distress and ethical climate in a Swedish nursing context:perceptions and instrument usability
Open this publication in new window or tab >>Moral distress and ethical climate in a Swedish nursing context:perceptions and instrument usability
Show others...
2011 (English)In: Journal of Clinical Nursing, ISSN 0962-1067, E-ISSN 1365-2702, Vol. 20, no 23-24, 3483-3493 p.Article in journal (Refereed) Published
Abstract [en]

Aim. The aim was fivefold: to describe Swedish nurses' perceptions of moral distress and determine whether there were differences in perceptions depending on demographic characteristics and to describe the usability of the Moral Distress Scale in a Swedish context. Further, the aim was to describe Swedish nurses' perceptions of ethical climate and the relationship between moral distress and ethical climate.

Background. Moral distress has been studied for more than two decades and the Moral Distress Scale is the most widely used instrument for measuring it. Moral distress has mainly been studied in relation to nurses' characteristics, but increasing attention has been paid to contextual aspects, such as ethical climate, that could be associated with moral distress.

Design. Descriptive, with a quantitative approach.

Methods. The study used two questionnaires: the Moral Distress Scale and the Hospital Ethical Climate Survey. The study was carried out at two hospitals in Sweden and included 249 nurses.

Results. Both level and frequency of moral distress were low, however level of moral distress was high in situations when the patient was not given safe and proper care. Generally, the frequency of moral distress was lower than the level. Of the situations on the Moral Distress Scale, 13 of the 32 were considered irrelevant by 10-50% of the participants. The more positive the ethical climate was perceived to be, the less frequentely morally distressing situations were reported.

Conclusions. Since a positive ethical climate was associated with less frequent occurencies of moral distress, it should be investigated what contributes to a positive ethical climate. To be used in a Swedish context, the Moral Distress Scale needs further revision.

Relevance to clinical practice. Open dialouges at wards are encouraged regarding what practices contribute to a positive ethical climate.

Keyword
ethical climate, moral distress, nurses, questionnaires, Sweden
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-16264 (URN)10.1111/j.1365-2702.2011.03753.x (DOI)
Available from: 2011-10-10 Created: 2011-10-10 Last updated: 2012-01-02Bibliographically approved
4. What actions promote a positive ethical climate? A critical incident study of nurses’ perceptions
Open this publication in new window or tab >>What actions promote a positive ethical climate? A critical incident study of nurses’ perceptions
Show others...
2012 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 19, no 4, 501-512 p.Article in journal (Refereed) Published
Abstract [en]

There is a lack of qualitative studies exploring the phenomenon of positive ethical climate and what is perceived as promoting it. Therefore, the aim of this study was to explore and describe actions that acute care ward nurses perceive as promoting a positive ethical climate. The critical incident technique was used. Interviews were conducted with 20 nurses at wards where the ethical climate was considered positive, according to a previous study. Meeting the needs of patients and next of kin in a considerate way, as well as receiving and giving support and information within the work group, promoted a positive ethical climate. Likewise, working as a team with a standard for behaviour within the work group promoted a positive ethical climate. Future research needs to investigate other conditions that might also promote a positive ethical climate.

Keyword
ethical climate, nurses, interviews, critical incident technique
National Category
Nursing
Identifiers
urn:nbn:se:hj:diva-16265 (URN)10.1177/0969733011436204 (DOI)
Available from: 2011-10-10 Created: 2011-10-10 Last updated: 2014-09-17Bibliographically approved

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