Ten nurses at a university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and physicians about being in ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. The main theme in the narratives was being close to and moved by the suffering of patients and relatives. The nurses' responsibility for patients and relatives was expressed as a commitment to act, and they needed to ask themselves (...) whether their responsibility had been fulfilled, that nothing had been left undone, overlooked or neglected, before they could leave the unit. When there was confirmation by the patients, relatives, colleagues and themselves that the needs of patients and relatives had been attended to in a morally and professionally satisfying manner, this increased the nurses' confidence and satisfaction in their work, and their strength to live with the burden of being in ethically difficult situations. (shrink)

Abstract In the last few decades, a growing number of commentators have questioned the appropriateness of the 'justice view' of ethics as a suitable approach in health care ethics, and most certainly in nursing. Essentially, in their ethical deliberations, it is argued that nurses do not readily adopt the high degree of impartiality and objectivity that is associated with a justice view; instead their moral practices are more accurately reflected through the use of alternative approaches such as relational or care-based (...) ethics. Yet, it has also been argued that this viewpoint does not necessarily 'do justice' to the broader moral responsibilities of nurses towards humanity in general, i.e. to the wider socio-cultural and socio-political issues in society, and to the concept of social justice in particular. This criticism has triggered a much closer examination of relational and care-based ethics in nursing at levels beyond individual responsiveness within relationships and brought into the spotlight the need for a more ethically refined nursing response to an increasingly complex set of socio-cultural inequalities. This article explores a relational ethic within nursing practices with contemporary ideas regarding social justice. In particular, it is argued that the synergy between the two actually produces an ethic that is capable of not only challenging the continuing predominance of justice-based ethics within health care, but of replacing it. Subsequently, in the discussion that follows, it is suggested that a combined social justice and relational care-based approach, as a social ethic, should guide the moral deliberations and actions of nurses. It is maintained that such an approach is not only possible, but crucial if nurses are to realize their full potential as ethical agents for individual and social good. © 2011 Blackwell Publishing Ltd. (shrink)

Background: For the experience of end-of-life care to be ‘good’ many ethical challenges in various relationships have to be resolved. In this article, we focus on challenges in the nurse–next of kin relationship. Little is known about difficulties in this relationship, when the next of kin are seen as separate from the patient. Research problem: From the perspective of nurses: What are the ethical challenges in relation to next of kin in end-of-life care? Research design: A critical qualitative approach was (...) used, based on four focus group interviews. Participants: A total of 22 registered nurses enrolled on an Oncology nursing specialisation programme with experience from end-of-life care from various practice areas participated. Ethical considerations: The study was approved by the Norwegian Social Science Data Service, Bergen, Norway, project number 41109, and signed informed consent obtained from the participants before the focus groups began. Findings and discussion: Two descriptive themes emerged from the inductive analysis: ‘A feeling of mistrust, control and rejection’ and ‘Being between hope and denial of next of kin and the desire of the patient to die when the time is up’. Deductive reinterpretation of data (in the light of moral distress from a Feminist ethics perspective) has made visible the constraints that certain relations with next of kin in end-of-life care lay upon the nurses’ moral identity, the relationship and their responsibility. We discuss how these constraints have political and societal dimensions, as well as personal and relational ones. Conclusion: There is complex moral distress related to the nurse–next of kin relationship which calls for ethical reflections regarding these relationships within end-of-life care. (shrink)

This article aims to deepen the understanding of courage through a theoretical analysis of classical philosophers’ work and a review of published and unpublished empirical research on courage in nursing. The authors sought answers to questions regarding how courage is understood from a philosophical viewpoint and how it is expressed in nursing actions. Four aspects were identified as relevant to a deeper understanding of courage in nursing practice: courage as an ontological concept, a moral virtue, a property of an ethical (...) act, and a creative capacity. The literature review shed light on the complexity of the concept of courage and revealed some lack of clarity in its use. Consequently, if courage is to be used consciously to influence nurses’ ethical actions it seems important to recognize its specific features. The results suggest it is imperative to foster courage among nurses and student nurses to prepare them for ethical, creative action and further the development of professional nursing practices. (shrink)

In this article we attempt to situate nursing within the interprofessional care team with respect to processes of ethical practice and ethical decision making. After briefly reviewing the concept of interprofessionalism, the idea of a nursing ethic as ‘unique’ within the context of an interprofessional team will be explored. We suggest that nursing’s distinct perspective on the moral matters of health care stem not from any privileged vantage point but rather from knowledge developed through the daily activities of nursing practice. (...) Because of their position vis-à-vis patients and families in everyday clinical care, nurses cultivate ethical knowledge of at least two forms: (1) relational knowledge; and (2) embodied knowledge. Through the integration of these forms of knowledge, nurses develop a unique moral perspective and can make a meaningful contribution to the realm of ethics in interprofessional care. (shrink)

Every day situations arising in health care contain ethical issues influencing care providers' conscience. How and to what extent conscience is influenced may differ according to how conscience is perceived. This study aimed to explore the relationship between perceptions of conscience and stress of conscience among care providers working in municipal housing for elderly people. A total of 166 care providers were approached, of which 146 (50 registered nurses and 96 nurses' aides/enrolled nurses) completed a questionnaire containing the Perceptions of (...) Conscience Questionnaire and the Stress of Conscience Questionnaire. A multivariate canonical correlation analysis was conducted. The first two functions emerging from the analysis themselves explained a noteworthy amount of the shared variance (25.6% and 17.8%). These two dimensions of the relationship were interpreted either as having to deaden one's conscience relating to external demands in order to be able to collaborate with coworkers, or as having to deaden one's conscience relating to internal demands in order to uphold one's identity as a `good' health care professional. (shrink)

Background The aim of this study was to describe the kinds of ethical dilemmas surgeons face during practice. Methods Five male and five female surgeons at a University hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of physicians and nurses about ethically difficult situations in surgical units. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. Results No gender differences were found in the kinds of ethical dilemmas identified among male and female surgeons. (...) The main finding was that surgeons experienced ethical dilemmas in deciding the right treatment in different situations. The dilemmas included starting or withholding treatment, continuing or withdrawing treatment, overtreatment, respecting the patients and meeting patients' expectations. The main focus in the narratives was on ethical dilemmas concerning the patients' well-being, treatment and care. The surgeons narrated about whether they should act according to their own convictions or according to the opinions of principal colleagues or colleagues from other departments. Handling incompetent colleagues was also seen as an ethical dilemma. Prioritization of limited resources and following social laws and regulations represented ethical dilemmas when they contradicted what the surgeons considered was in the patients' best interests. Conclusion The surgeons seemed confident in their professional role although the many ethical dilemmas they experienced in trying to meet the expectations of patients, colleagues and society also made them professionally and personally vulnerable. (shrink)

Public health nursing is grounded in public health ideologies and fundamental nursing values. Researchers have argued that ethical responsibility from the perspective of the nurse is an understudied phenomenon. This meta-ethnography provides in-depth knowledge of how public health nurses (PHNs) experience ethical responsibility when working to prevent injury and disease, and promote health and well-being in children, young people and their families. There are reciprocal findings across the 10 included studies. The findings reveal that these nurses often feel alone, have (...) worries and uncertainties and are afraid of doing wrong. They describe unclear boundaries in their work, creating a heightened sense of responsibility. PHNs fight lonely battles. Yet they show courage and commitment and are ready to stand up and fight for children and families who do not receive adequate care. A line of argument is developed and the metaphorical phrase Chivalrous knights in moral armour is used to express the authors’ overall interpretations of the findings. Reflection on the findings shows how the different dimensions of ethical responsibility are interconnected. The nurses’ ethical sensitivity enables them to feel compassion for others and they show indignation when vulnerable others are not treated with dignity and respect. Indignation and compassion are interrelated, and when human life and dignity are threatened, the ethical demand to respond emerges. Indignation is a precursor to moral courage, and the nurses’ moral sensitivity and respect for their clients emboldens them to stand up for vulnerable others. The findings also illustrate the paradoxical nature of freedom. Freedom of choice due to unclear boundaries heightens the nurses' sense of responsibility. This research is an important step in theory development and has implications for further research, education and practice. (shrink)

Background: Legislative changes are resulting in assisted death as an option for people at the end of life. Although nurses’ experiences and perspectives are underrepresented within broader ethical discourses about assisted death, there is a small but significant body of literature examining nurses’ experiences of caring for people who request this option. Aim: To synthesize what has been learned about nurses’ experiences of caring for patients who request assisted death and to highlight what is morally at stake for nurses who (...) undertake this type of care. Design: Qualitative meta-synthesis. Methods: Six databases were searched: CINAHL, Medline, EMBASE, Joanna Briggs Institute, PsycINFO, and Web of Science. The search was completed on 22 October 2014 and updated in February 2016. Of 879 articles identified from the database searches, 16 articles were deemed relevant based on inclusion criteria. Following quality appraisal, 14 studies were retained for analysis and synthesis. Results: The moral experience of the nurse is (1) defined by a profound sense of responsibility, (2) shaped by contextual forces that nurses navigate in everyday end-of-life care practice, and (3) sustained by intra-team moral and emotional support. Discussion: The findings of this synthesis support the view that nurses are moral agents who are deeply invested in the moral integrity of end-of-life care involving assisted death. The findings further demonstrate that to fully appreciate the ethics of assisted death from a nursing standpoint, it is necessary to understand the broader constraints on nurses’ moral agency that operate in everyday end-of-life care. Ethical considerations: Research ethics board approval was not required for this synthesis of previously published literature. Conclusion: In order to understand how to enact ethical practice in the area of assisted death, the moral experiences of nurses should be investigated and foregrounded. (shrink)

Background: Explicating nurses’ moral identities is important given the powerful influence moral identity has on the capacity to exercise moral agency. Research objectives: The purpose of this study was to explore how nurses narrate their moral identity through their understanding of their work. An additional purpose was to understand how these moral identities are held in the social space that nurses occupy. Research design: The Registered Nurse Journal, a bimonthly publication of the Registered Nurses’ Association of Ontario, Canada, features a (...) regular column entitled, ‘In the End … What Nursing Means to Me …’ These short narratives generally include a story of an important moment in the careers of the authors that defined their identities as nurses. All 29 narratives published before June 2015 were analysed using a critical narrative approach, informed by the work of Margaret Urban Walker and Hilde Lindemann, to identify a typology of moral identity. Ethical considerations: Ethics approval was not required because the narratives are publicly available. Findings: Two narrative types were identified that represent the moral identities of nurses as expressed through their work: (1) making a difference in the lives of individuals and communities and (2) holding the identities of vulnerable individuals. Discussion: Nurses’ moral identities became evident when they could see improvement in the health of patients or communities or when they could maintain the identity of their patients despite the disruptive forces of illness and hospitalization. In reciprocal fashion, the responses of their patients, including expressions of gratitude, served to hold the moral identities of these nurses. Conclusion: Ultimately, the sustainability of nurses’ moral identities may be dependent on the recognition of their own needs for professional satisfaction and care in ways that go beyond the kind of acknowledgement that patients can offer. (shrink)

Changes in health care have created a variety of new roles and opportunities for nurses in advanced practice. One of these changes is the increasing number of advanced practice nurses carrying out independent consultation. Differences in goals between business and health care may create ethical dilemmas for nurse consultants. The purpose of this article is to describe possible ethical pitfalls that nurse consultants may encounter and strategies to prevent or solve these dilemmas. Three themes related to nursing codes of ethics (...) will be discussed: the duty to uphold human rights, the duty to fulfill commitments, and the duty to practice the profession competently. (shrink)

Departing from a contemporary novel about a boy who is going to die from leukaemia, this article shows how the dimension of time can be seen as a morally relevant category that bridges both ‘dramatic’ issues, which constitute the dominant focus of bioethical decision making, and ‘undramatic’ issues, which characterize the lived experience of patients, relatives and health care workers. The moral task of comparing the various time dimensions of a given situation is explained as an act of ‘synchronizing’ the (...) clocks. Ethical sensitivity and competence are presented as core skills that allow a continuity of care in situations where dramatic issues seem to be resolved, but undramatic ones are still not addressed. A nine-step model of shared decision making is proposed as an approach to identifying critical junctures within an illness trajectory and synchronizing the clocks of the involved actors. (shrink)

This article reports a study exploring the meaning of the complex phenomenon of moral responsibility in nursing practice. Each of three focus groups with a total of 14 student nurses were conducted twice to gather their views on moral responsibility in nursing practice. The data were analysed by qualitative thematic content analysis. Moral responsibility was interpreted as a relational way of being, which involved guidance by one’s inner compass composed of ideals, values and knowledge that translate into a striving to (...) do good. It was concluded that, if student nurses are to continue striving to do good in a way that respects themselves and other people, it is important that they do not feel forced to compromise their values. Instead they should be given space and encouragement in their endeavours to do good in a relational way that advances nursing as a moral practice. (shrink)

Background The aim of this study was to explore the ethical challenges in surgery from the surgeons' point of view and their experience of being in ethically difficult situations. Methods Five male and five female surgeons at a university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and physicians about being in such situations. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. Results No differences in ethical reasoning between male and (...) female surgeons were found. They reasoned in both action and relational ethical perspectives. Surgeons focused on their relationships with patients and colleagues and their moral self in descriptions of the ethical challenges in their work. Dialogue and personal involvement were important in their relationships with patients. The surgeons emphasized the importance of open dialogue, professional recognition, and an inclusive and accepting environment between colleagues. Conclusion The surgeons are personally challenged by the existential realities of human life in their relationships with patients. They realized that ethical challenges are an inherent part of performing surgery and of life itself, and say that they have to learn to "live with" these challenges in a way that is confirmed both socially and by their inner moral self. This means accepting their personal and professional limitations, being uncertain, being fallible, and being humble. Living with the ethical challenges of surgery seems to contribute to the surgeons' confidence and vulnerability in their professional identity. (shrink)

Background: Ethical codes are guidelines that orient nurses and ensure that their decisions are in accordance with the values of the professional system. These codes show that there is a connection among values, patients’ rights, and nurses’ duties. Objectives: This study aimed to compare the viewpoints of patients, nurses, and nurse managers regarding the extent to which clinical ethical codes are observed. Research design: In this descriptive–comparative study, data were collected using three questionnaires based on Iranian nurses’ ethical codes with (...) a focus on clinical care. The reliability of the questionnaire was verified by test–retest method (r = 0.9). The patients were interviewed by the researcher, but nurses and managers completed the questionnaires themselves. After all, the data were analyzed using the SPSS statistical software (v 15). Participants and research context: In all, 100 patients, 100 nurses, and 30 managers from internal and surgical wards of two major hospitals in Shiraz, Iran, participated in 2014. Ethical considerations: This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants signed written informed consents. Findings: According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses’ adherence to ethical codes as satisfactory. The mean scores (standard deviation) of the level of adherence to ethical codes were 38.44 (6.91) in the patients, 41.08 (4.82) in the nurses, and 37.83 (6.98) in the nurse managers. The results of analysis of variance revealed a significant difference between the attitudes of the nurses and the other two groups (p = 0.001). Discussion: Nurses’ adherence to ethical codes was satisfactory in all three groups. Accordingly, our findings agree with the results of some national and international studies, although there are still controversies in this regard. Conclusion: Although the nurses rated their performance in certain fields more satisfactory compared to the patients and managers, all the three groups agreed that clinical ethical codes were properly observed in the internal and surgical wards. Nurses can improve the quality of care by considering the viewpoints of patients and managers about their ethical performance. (shrink)

Background: Nursing practice takes place in a social framework, in which environmental elements and interpersonal relations interact. Ethical climate of the work unit is an important element affecting nurses’ professional and ethical practice. Nevertheless, whatever the environmental circumstances, nurses are expected to be professionally competent providing high-quality care ethically and clinically. Aim: This study examined newly graduated nurses’ perception of the ethical climate of their work environment and its association with their self-assessed professional competence, turnover intentions and job satisfaction. Method: (...) Descriptive, cross-sectional, correlational research design was applied. Participants consisted of 318 newly graduated nurses. Data were collected electronically and analysed statistically. Ethical considerations: Ethical approval and permissions to use instruments and conduct the study were obtained according to required procedures. Data were rendered anonymous to protect participant confidentiality. Completing the questionnaire was interpreted as consent to participate. Findings: Nurses’ overall perception of the ethical climate was positive. More positive perceptions related to peers, patients and physicians, and less positive to hospitals and managers. Strong associations were found between perceived ethical climate and self-assessed competence, turnover intentions in terms of changing job, and job satisfaction in terms of quality of care. Nurses at a higher competence level with positive views of job satisfaction and low turnover intentions perceived the climate significantly more positively. Conclusion: Nursing management responsible for and having the power to implement changes should understand their contribution in ethical leadership, as well as the multidimensional nature of nurses’ work environment and the interaction between work-related factors in planning developmental measures. Future research should focus on issues in nurse managers’ ethical leadership in creating ethical work environments. There is also a need for knowledge of newly graduated nurses’ views of factors which act as enhancers or barriers to positive ethical climates to develop. Interventions, continuing education courses, and discussions designed to promote positive ethical climates should be developed for managers, nurses, and multi-professional teams. (shrink)

Background:Ethical codes are guidelines that orient nurses and ensure that their decisions are in accordance with the values of the professional system. These codes show that there is a connection among values, patients’ rights, and nurses’ duties.Objectives:This study aimed to compare the viewpoints of patients, nurses, and nurse managers regarding the extent to which clinical ethical codes are observed.Research design:In this descriptive–comparative study, data were collected using three questionnaires based on Iranian nurses’ ethical codes with a focus on clinical care. (...) The reliability of the questionnaire was verified by test–retest method. The patients were interviewed by the researcher, but nurses and managers completed the questionnaires themselves. After all, the data were analyzed using the SPSS statistical software.Participants and research context:In all, 100 patients, 100 nurses, and 30 managers from internal and surgical wards of two major hospitals in Shiraz, Iran, participated in 2014.Ethical considerations:This research was approved by the Ethics Committee of Shiraz University of Medical Sciences. All the participants signed written informed consents.Findings:According to the results, 70% of the patients, 86% of the nurses, and 53.3% of the nurse managers rated nurses’ adherence to ethical codes as satisfactory. The mean scores of the level of adherence to ethical codes were 38.44 in the patients, 41.08 in the nurses, and 37.83 in the nurse managers. The results of analysis of variance revealed a significant difference between the attitudes of the nurses and the other two groups.Discussion:Nurses’ adherence to ethical codes was satisfactory in all three groups. Accordingly, our findings agree with the results of some national and international studies, although there are still controversies in this regard.Conclusion:Although the nurses rated their performance in certain fields more satisfactory compared to the patients and managers, all the three groups agreed that clinical ethical codes were properly observed in the internal and surgical wards. Nurses can improve the quality of care by considering the viewpoints of patients and managers about their ethical performance. (shrink)

The limitations of rational models of ethical decision making and the importance of nurses’ human involvement as moral agents is increasingly being emphasized in the nursing literature. However, little is known about how nurses involve themselves in ethical decision making and action or about educational processes that support such practice. A recent study that examined the meaning and enactment of ethical nursing practice for three groups of nurses (nurses in direct care positions, student nurses, and nurses in advanced practice positions) (...) highlighted that humanly involved ethical nursing practice is also simultaneously a personal process and a socially mediated one. Of particular significance was the way in which differing role expectations and contexts shaped the nurses’ ethical practice. The study findings pointed to types of educative experiences that may help nurses to develop the knowledge and ability to live in and navigate their way through the complex, ambiguous and shifting terrain of ethical nursing practice. (shrink)

Background: Ethical issues associated with nurses’ interactions with industry have implications for the safety, quality, and cost of healthcare. To date, little work has explored nurse–industry interactions and their associated ethical issues empirically. Design and participants: A phenomenological study was conducted to explore registered nurses’ interactions with industry in clinical practice. Five registered nurses working in direct patient care were recruited and individual, in-depth interviews were conducted. The University’s Committee on Human Research approved the study. Findings: Nurses frequently interacted with (...) industry in their practice and felt ambivalent about these interactions. Nurses described systemic cuts to multiple “goods” central to nursing practice, including patient support, but paradoxically relied on industry resources to deliver these “goods.” They relied on a particular conception of trust to navigate these interactions but were left to do so individually on the basis of their experience. Conflicts of interest arose as a result of multiple competing interests, and were frequently mediated through nurses’ superiors. Conclusion: Nursing as a profession requires a guiding narrative to aid nurses in interpreting and navigating interactions with industry. A conception of trust that incorporates both the work of caring and attention to social justice could form the basis of these interactions, but would require that nursing take a much more critical stance toward marketing interactions. (shrink)

In the closed wards of mental health institutions, moral decisions are made concerning the use of forced seclusion. In this article we focus on how these moral decisions are made and can be improved. We present a case study concerning moral deliberations on the use of seclusion and its prevention among nurses of a closed mental health ward. Moral psychology provides an explanation of how moral judgments are developed through processes of interaction. We will make use of the Social Intuitionist (...) Model of Jonathan Haidt that emphasizes the role of emotions, intuitions and the social context in moral judgments and reasoning. We argue that this model can help to explain social dynamics in the context of enforced seclusion. In the discussion we explore how moral psychology can be complemented with the normative perspective of dialogical ethics to develop strategies for improving psychiatric practices. We conclude that social processes play an important role in moral deliberations and that moral development can be fostered by bringing in new perspectives in the dialogue. Moral case deliberation provides a practical tool to systematically organize moral reflections among nurses on the work floor. (shrink)

This article deals with the question of how ethicists respond to practical moral problems emerging in health care practices. Do they remain distanced, taking on the role of an expert, or do they become engaged with nurses and other participants in practice and jointly develop contextualized insights about good care? A basic assumption of dialogical ethics entails that the definition of good care and what it means to be a good nurse is a collaborative product of ongoing dialogues among various (...) stakeholders engaged in the practice. This article discusses the value of a dialogical approach to ethics by drawing on the work of various nursing scholars. We present a case example concerning the quality of freedom restrictions for intellectually disabled people. Issues for discussion include the role and required competences of the ethicist and dealing with asymmetrical relationships between stakeholders. (shrink)

Troubled conscience may jeopardize the health of healthcare personnel and, hence, the quality of care provided. Learning more about how personnel deal with their troubled conscience therefore seems important. The aim of this study was to describe personnel’s experiences of how they deal with troubled conscience generated in their daily work in municipal care of older people. Interviews were conducted with 20 care providers and analysed with a thematic content analysis. The findings show that in order to deal with troubled (...) conscience, personnel dialogued with themselves and with others. They took measures in a direction they perceived to be correct, and they expressed a need for distancing and re-energizing. It is of importance to share situations that generate troubled conscience in order to find ways to deal with them. Reconsidering one’s ways of dealing with troubled conscience may give care providers an opportunity to reach consensus within themselves. (shrink)