Background:Ethical conflict and subsequent nurse moral distress and burnout are common in the intensive care unit (ICU). There is a gap in our understanding of nurses’ perceptions of how organizational resources support them in addressing ethical conflict in the intensive care unit.Research question/objectives/methods:The aim of this qualitative, descriptive study was to explore how nurses experience ethical conflict and use organizational resources to support them as they address ethical conflict in their practice.Participants and research context:Responses to two open-ended questions were collected (...) from critical care nurses working in five intensive care units at a large, academic medical center in the Midwestern region of the United States.Ethical considerations:This study was approved by the Institutional Review Board at the organization where the study took place.Findings:Three main interwoven themes emerged: nurses perceive (1) intensive care unit culture, practices, and organizational priorities contribute to patient suffering; (2) nurses are marginalized during ethical conflict in the intensive care unit; and (3) organizational resources have the potential to reduce nurse moral distress. Nurses identified ethics education, interprofessional dialogue, and greater involvement of nurses as important strategies to improve the management of ethical conflict.Discussion:Ethical conflict related to healthcare system challenges is intrinsic in the daily practice of critical care nurses. Nurses want to be engaged in discussions about their perspectives on ethical conflict and play an active role in addressing ethical conflict in their practice. Organizational resources that support nurses are vital to the resolution of ethical conflict.Conclusion:These findings can inform the development of interventions that aim to proactively and comprehensively address ethical conflict in the intensive care unit to reduce nurse moral distress and improve the delivery of patient and family care. (shrink)

Background: Moral distress is a complex phenomenon frequently experienced by critical care nurses. Ethical conflicts in this practice area are related to technological advancement, high intensity work environments, and end-of-life decisions. Objectives: An exploration of contemporary moral distress literature was undertaken to determine measurement, contributing factors, impact, and interventions. Review Methods: This state of the science review focused on moral distress research in critical care nursing from 2009 to 2015, and included 12 qualitative, 24 quantitative, and 6 mixed methods studies. (...) Results: Synthesis of the scientific literature revealed inconsistencies in measurement, conflicting findings of moral distress and nurse demographics, problems with the professional practice environment, difficulties with communication during end-of-life decisions, compromised nursing care as a consequence of moral distress, and few effective interventions. Conclusion: Providing compassionate care is a professional nursing value and an inability to meet this goal due to moral distress may have devastating effects on care quality. Further study of patient and family outcomes related to nurse moral distress is recommended. (shrink)

Moral distress has emerged as a significant concern for critical care nurses, particularly due to the complex and demanding care provided to critically ill patients in critical care units. The ongoing COVID-19 pandemic has introduced new ethical challenges and changes in clinical practice, further exacerbating the experience of moral distress among these nurses. This systematic review compares the factors influencing moral distress among critical care nurses before and during the COVID-19 pandemic to gain a comprehensive understanding of the impact of (...) the pandemic on moral distress. For this systematic review, PubMed, Scopus, ProQuest, Web of Science, medRxiv, bioRxiv, Embase, and Google Scholar were all utilized in the search. The search covered articles published from 2012 to December 2022, encompassing a 10-year timeframe to capture relevant research on moral distress among critical care nurses. In total, 52 articles were included in this systematic review. The findings indicate that personal, caring-related, and organizational factors can influence nurses' moral distress. Before the pandemic, factors including futile and end-of-life care, conflicts with physicians, nurse performance and authority, poor teamwork, decision-making regarding treatment processes and patient care, limited human resources and equipment, medical errors, patient restraints, and nurses' age and work experience affect critical care nurses' moral distress. Similarly, during the COVID-19 pandemic, factors contributing to moral distress include futile and end-of-life care, fear of contracting and spreading COVID-19, decision-making about treatment processes, poor teamwork, and being female. This study revealed that the factors contributing to moral distress were approximately similar in both periods. Futile care and end-of-life issues were critical care nurses' primary causes of moral distress. Implementing prevention strategies and reducing these underlying factors could decrease this major issue and improve the quality of care. (shrink)

Background: Whenever there has been a worldwide contagious disease outbreak, there have been reports of infection and death of healthcare workers. Particularly because emergency nurses have contact with patients on the front line, they experience ethical problems in nursing while struggling with infectious diseases in an unfavorable environment. Objective: The objective of this study was to explore emergency nurses’ ethical problems and to identify factors influencing these problems during the outbreak of Middle East respiratory syndrome–coronavirus in Korea. Design and sample: (...) For this cross-sectional study, a questionnaire survey was conducted with emergency nurses working in six hospitals selected through convenience sampling from the hospitals designated for Middle East respiratory syndrome–coronavirus patients in the capital area. Methods: Data were collected from 169 emergency nurses in Korea during August 2015. Ethical considerations: This research was approved by the Institutional Review Board of G University in Korea. Results: The findings of this study suggest that during the Middle East respiratory syndrome–coronavirus outbreak, emergency nurses experienced ethical problems tied to a mind-set of avoiding patients. Three factors were found to influence emergency nurses’ ethical problems (in order of influence): cognition of social stigmatization, level of agreement with infection control measures, and perceived risk. Conclusion: Through this study, we obtained information on emergency nurses’ ethical problems during the Middle East respiratory syndrome–coronavirus outbreak and identified the factors that influence them. As found in this study, nurses’ ethical problems were influenced most by cognitions of social stigmatization. Accordingly, to support nurses confidently care for people during future health disasters, it is most urgent to promote appropriate public consciousness that encourages healthcare workers. (shrink)

Background: Ethical conflict is a barrier to decision-making process and is a problem derived from ethical responsibilities that nurses assume with care. Intensive care unit nurses are potentially exposed to this phenomenon. A deep study of the phenomenon can help prevent and treat it. Objectives: This study was aimed at determining the frequency, degree, level of exposure, and type of ethical conflict among nurses working in the intensive care units. Research design: This was a descriptive cross-sectional research. Participants and research (...) context: In total, 382 nurses working in the intensive care units in Iranian hospitals were selected using the random sampling method. Data were collected using the Ethical Conflict in Nursing Questionnaire-Critical Care Version (Persian version). Ethical considerations: This study was approved by the Medical Research Ethics Committee. Ethical considerations such as completing the informed consent form, ensuring confidentiality of information, and voluntary participation were observed. Findings: The results showed that the average level of exposure to ethical conflict was 164.39 ± 79.06. The most frequent conflict was related to “using resources despite believing in its futility,” with the frequency of at least once a week or a month (68.6%, n = 262). The most conflictive situation was violation of privacy (76.9%, n = 294). However, the level of exposure to ethical conflict according to the theoretical model followed was the situation of “working with incompetent staff.” The most frequently observed type of conflict was moral dilemma. Conclusion: The moderate level of exposure to ethical conflict was consistent with the results of previous studies. However, the frequency, degree, and type of ethical conflict were different compared to the results of other studies. Recognizing ethical conflict among intensive care unit nurses can be useful as it allows to consolidate those measures that favor low levels of ethical conflict, design appropriate strategies to prevent ethical conflicts, and improve the nursing work environment. (shrink)

Introduction: Critical care nurses work in a complex and stressful environment with diverse norms, values, interactions, and relationships. Therefore, they inevitably experience some levels of ethical conflict. Aim: The aim of this study is to analyze the relationship of ethical conflict with personal and organizational characteristics among critical care nurses. Methods: This descriptive-correlational study was conducted in 2017 on a random sample of 216 critical care nurses. Participants were recruited through stratified random sampling. Data collection tools were a demographic and (...) professional characteristics questionnaire, the Ethical Conflict in Nursing Questionnaire-Critical Care Version, and the Organizational and Managerial Factors Questionnaire. The data were analyzed using the SPSS software (v. 22.0). Ethical considerations: All participants were informed about the study’s aim and were assured that participation in and withdrawal from the study would be voluntary. Findings: The mean score of exposure to ethical conflict was 201.91 ± 80.38. The highest-scored conflict-inducing clinical situation was “working with professionally incompetent nurses or nurse assistants.” Married nurses, nurses with official employment, nurses with master’s degree, and nurses with the history of attending ethics education programs had significantly higher exposure to ethical conflict than the other nurses (p < 0.05). The significant predictors of exposure to ethical conflict were marital status, educational status, reward system, organizational culture, manager’s conduct, and organizational structure and regulations (p < 0.05). These predictors accounted for 37.2% of the total variance of exposure to ethical conflict. Conclusion: Critical care nurses experience moderate levels of exposure to ethical conflict. A wide range of personal and organizational factors can contribute to such exposure, the most significant of which is the professional incompetence of nursing colleagues, nurse assistants, and physicians. Therefore, many improvements at personal and organizational levels are needed to reduce critical care nurses’ exposure to ethical conflict. (shrink)

Background Intensive care nurses frequently encounter ethical issues with potentially severe consequences for nurses, patients, and next of kin. Therefore, ethical issues in intensive care units (ICU) should be recognized and managed. Research objectives To analyze ethical issues reported by intensive care nurses and how reported issues were managed within the organization using register data from the HaiPro critical incident reporting system (CIRS), and to explore the suitability of this system for reporting and managing ethical issues. Research design This was (...) a retrospective descriptive register study. CIRS reports on ethical issues in adult ICUs ( n = 12) in one hospital district in Finland over 25 months (2019–2021) were analyzed through inductive content analysis and descriptive quantification. The CIRS’s suitability for reporting and managing ethical issues was evaluated through a strengths, weaknesses, opportunities, and threats (SWOT) analysis. Ethical considerations The study was approved by the University Ethics Committee, and permission to conduct the research was granted before data collection within the organization. Results CIRS reports on ethical issues ( n = 35) made by nurses were found in seven of the 12 ICUs. The CIRS managers of these units managed these reports. The ethical issues described by the nurses were divided into four main categories: nature, situational information, consequences, and contributing factors. Management of reported ethical issues was divided into three main categories: preventive actions proposed by nurses, proposals for actions by CIRS managers, and actions taken by CIRS managers. Conclusions Systematic register data broadly describe ethical issues and their management, indicating that the CIRS could be suitable for reporting and managing ethical issues, thereby enabling the monitoring and development of ethical quality at the unit and organizational levels. (shrink)

Introduction: Ethical conflict is a phenomenon that has been under study over the last three decades, especially the types moral dilemma and moral distress in the field of nursing care. However, ethical problems and their idiosyncrasies need to be further explored. Aim: The objectives of this study were, first, to obtain a transcultural Portuguese-language adaptation and validation of the Ethical Conflict Nursing Questionnaire–Critical Care Version and, second, to analyse Portuguese critical care nurses’ level of exposure to ethical conflict and its (...) characteristics. Methods: A cross-cultural validation and descriptive, prospective and correlational study. The sample was made for 184 critical care nurses in 2016. Ethical Considerations: The study was authorised by Bioethics Commission of the University of Barcelona, the Associaçâo de Apoio ao Serviço de Cuidados Intensivos do Centro Hospitalar do Porto and the Sociedade Portuguesa de Enfermagem de Saúde Mental. Findings: The Portuguese version of the Ethical Conflict Nursing Questionnaire–Critical Care Version was a valid and reliable instrument to measure exposure to conflict. Moral outrage was the most common type of conflict. The most problematic situations were the ineffectiveness of analgesic treatments, the administration of treatments considered futile and the mismanagement of resources. (shrink)

Background: A growing body of evidence about nurses’ ethical conflicts has been added to nursing science in recent decades, but no research has been done in Estonia. Ethical conflicts are a cultural and context sensitive phenomenon, so the historical, legal, social, economic and political backgrounds and position of nursing have had an impact on ethical conflict experiences. Aim: Describe nurses’ experiences of ethical conflicts. Method: A qualitative, descriptive study was conducted among nurses (n = 21) in May-October 2018 in Estonia. (...) The data were collected in the form of semi-structured individual interviews and analysed using the inductive content analysis method. Ethical considerations: Due to the sensitive nature of the research topic, only individual interviews were carried out. Findings: Nurses’ ethical conflicts were related to situations that violated the rights, safety or well-being of the patient or relatives, caused them suffering, were against their will or threatened nurses’ dignity and professionalism through a variety of practices, attitudes and relationships. The insufficiency of patient care and professional collaboration emerged as important sources of nurses’ ethical conflicts and were connected to historical and societal factors. Conclusions: In order to achieve good quality of care, nurses need to have appropriate education and organisational support to carry out ethical daily care. More research is needed to understand the multidimensional cultural and contextual knowledge of ethics and nurses’ ethical conflicts. (shrink)

Background Ethical conflict is a problem with negative consequences, which can compromise the quality and ethical standards of the nursing profession and it is a source of stress for health care practitioners’, especially for nurses. Objectives The main aim of this study was to analyze Spanish critical care nurses’ level of exposure to ethical conflict and its association with sociodemographic, occupational, and COVID-19–related variables. Research Design, Participants, and Research context: This was a quantitative cross-sectional descriptive study conducted among 117 nurses (...) working in critical care units. Data collection tools were sociodemographic, occupational, and COVID-19–related questionnaires and previously validated Spanish version of Ethical Conflict in Nursing Questionnaire-Critical Care Version. Ethical Considerations We obtained permission from the Ethics Committee and participants' informed consent. Findings Data indicates a moderate level of exposure to ethical conflicts. The most frequent ethical conflicts were related to situations about "treatment and clinical procedures." The most intensity of ethical conflicts was related to situations about "treatment and clinical procedures" and "dynamics of the service and working environment." No statistical significance was identified between the socio-demographic variables and level of exposure to ethical conflicts. However, for critical care nurses working in ICU, nurses with perceived worked stress had a higher level of exposure to ethical conflicts. Likewise, critical care nurses whose family/friends were infected with COVID-19 had a higher level of exposure. Conclusions Critical care nurses experience a moderate level of exposure to ethical conflicts which is consistent with the results of previous studies. A deeper understanding of ethical conflicts in conflictive situations allows recognition of the situations that occur in everyday clinical practice, identification of the ethical conflicts, and facilitation of the nurses working in the challenging clinical situation. (shrink)

Background: Despite the reported harms and ethical concerns about physical restraint use in the critical care settings, nurses’ intention to apply them is unequal across countries. According to the theory of planned behaviour, eliciting nurses’ beliefs regarding the use of physical restraints would provide additional social information about nurses’ intention to perform this practice. Aim: To explore the salient behavioural, normative and control beliefs underlying the intention of critical care nurses to use physical restraints from the theory of planned behaviour. (...) Research design: A belief elicitation study was conducted. Participants and research context: Twenty-six critical care nurses were purposively sampled across gender, work-shift patterns and professional experience in five intensive care units of three hospitals in Spain. Data were obtained from a nine-item open-ended questionnaire and a focus group. Deductive content analysis was performed. Ethical considerations: Ethical approval was obtained from the hospital ethics committee. Participants were assured their participation was voluntary. Findings: Nurses framed the use of restraints as a way of prioritising patients’ physical safety. They referred to contextual factors as the main reasons to justify their application. Nurses perceived that their decision is approved by other colleagues and the patients’ relatives. Some nurses started advocating against their use, but felt powerless to change this unsafe practice within an unfavourable climate. Control beliefs were linked to patients’ medical condition, availability of alternative solutions, analgo-sedation policies and work organisation. Discussion: Safety arguments based on the surrounding work environment were discussed. Conclusion: Nurses’ behavioural and control beliefs were related. Nurses should be trained in alternatives to physical restraint use. The impact of analgo-sedation protocols, relatives’ involvement, leadership support and intensive care unit restraint policies on physical restraint practices need to be revised. Further research is required to explore why nurses do not act with moral courage to change this harmful practice. (shrink)