Much of the literature on clinical ethical conflict has been specific to a specialty area or a particular patient group, as well as to a single profession. This study identifies themes of hospital nurses’ and physicians’ clinical ethical conflicts that cut across the spectrum of clinical specialty areas, and compares the themes identified by nurses with those identified by physicians. We interviewed 34 clinical nurses, 10 nurse managers and 31 physicians working at four different Canadian hospitals as part of a (...) larger study on clinical ethics committees and nurses’ and physicians’ use of these committees. We describe nine themes of clinical ethical conflict that were common to both hospital nurses and physicians, and three themes that were specific to physicians. Following this, we suggest reasons for differences in nurses’ and physicians’ ethical conflicts and discuss implications for practice and research. (shrink)

This study examined the association of nurses’ ethical conflict with hospitals with organizational commitment, stress, turnover intention, absence and turnover. Participants were 410 nurses working at four different Canadian hospitals. A longitudinal design was used where nurses completed a questionnaire to capture ethical conflict, stress and organizational commitment, and one year later, measures of turnover intention, absence and actual turnover were obtained for the same sample. We found three aspects of nurses’ ethical conflict with hospitals: patient care values, value of (...) nurses, and staffing policy values. Our findings showed that all three aspects of nurses’ ethical conflict are associated with stress and patient care values is associated with actual turnover. We also found that staffing policy values is predictive of turnover intention, and that patient care values is predictive of absenteeism. Thus, our findings show the multidimensionality of nurses’ ethical conflict with hospitals. Further implications of our findings for practice and theory are discussed. (shrink)

Since 1992, institutions accredited by The Joint Commission have been required to have a process in place that allows staff members, patients, and families to address ethical issues or issues prone to conflict. While the commission's expectations clearly have made ethics committees more common, simply having a committee in no way demonstrates its effectiveness in terms of the availability of the service to key constituents, the quality of the processes used, or the outcomes achieved. Beyond meeting baseline accreditation standards, effective (...) ethics resources are requisite for quality care for another reason. The provision of care to the sick is a practice with profound moral dimensions. Clinicians need what Margaret Urban Walker has called “moral spaces,” reflective spaces within institutions in which to explore and communicate values and ethical obligations as they undergird goals of care. Walker proposed that ethicists needed to be concerned with the design and maintenance of these moral spaces. Clearly, that concern needs to extend beyond ethicists to institutional leaders. This essay uses Walker's idea of moral space to describe individuals and groups who are actual and potential ethics resources in health care institutions. We focus on four requisite characteristics of effective resources and the challenges to achieving them, and we identify strategies to build them. In our view, such moral spaces are particularly important for nurses and their colleagues on interprofessional teams and need to be expanded and strengthened in most settings. (shrink)

Background: Nursing practice is complex, as nurses are challenged by increasingly intricate moral and ethical judgments. Inadequately studied in underrepresented groups in nursing, moral distress is a serious problem internationally for healthcare professionals with deleterious effects to patients, nurses, and organizations. Moral distress among nurses has been shown to contribute to decreased job satisfaction and increased turnover, withdrawal from patients, physical and psychological symptoms, and intent to leave current position or to leave the profession altogether. Research question: Do significant gender (...) differences exist in the moral distress scores of critical care nurses? Research design: This study utilized a quantitative, descriptive methodology to explore moral distress levels in a sample of critical care nurses to determine whether gender differences exist in their mean moral distress scores. Participants and research context: Participants ( n = 31) were critical care nurses from an American Internet nursing community who completed the Moral Distress Scale–Revised online over a 5-day period in July 2013. Ethical considerations: Institutional review board review approved the study, and accessing and completing the survey implied informed consent. Findings: The results revealed a statistically significant gender difference in the mean moral distress scores of participants. Females reported statistically significantly higher moral distress scores than did males. Overall, the moral distress scores for both groups were relatively low. Discussion: The findings of a gender difference have not previously been reported in the literature. However, other findings are consistent with previous studies on moral distress. Conclusion: Although the results of this study are not generalizable, they do suggest the need for continuing research on moral distress in underrepresented groups in nursing, including cultural and ethnic groups. (shrink)

Many studies examine a stressors-professional burnout (PB) relation, but only few consider the role of ethical conflicts (ECs) in this context. The aim of this study was to characterize ECs' frequency and level of burden with them among nurses and to establish the relations between ECs' frequency, burden and PB. One hundred nurses participated in this study. ECs' frequency and burden were tested with an originally developed questionnaire. PB was examined with Maslach Burnout Inventory. Most frequent ECs concerned a nurse-patient (...) relationship. PB was positively related to ECs' frequency (r = .54; p = .001) and burden (r = .22; p = .03). Frequency of specific conflict did not imply burden with it and vice versa. ECs' frequency seems more important for PB than a level of burden with them. The most frequent and the most burdening conflicts may lead to development of PB but the less frequent and less burdening ones are also dangerous. (shrink)

This study examined the relationship between moral distress intensity, moral distress frequency and the ethical work environment, and explored the relationship of demographic characteristics to moral distress intensity and frequency. A group of 106 nurses from two large medical centers reported moderate levels of moral distress intensity, low levels of moral distress frequency, and a moderately positive ethical work environment. Moral distress intensity and ethical work environment were correlated with moral distress frequency. Age was negatively correlated with moral distress intensity, (...) whereas being African American was related to higher levels of moral distress intensity. The ethical work environment predicted moral distress intensity. These results reveal a difference between moral distress intensity and frequency and the importance of the environment to moral distress intensity. (shrink)

Ethical conflicts are arising as a result of the growing complexity of clinical care, coupled with technological advances. Most studies that have developed instruments for measuring ethical conflict base their measures on the variables ‘frequency’ and ‘degree of conflict’. In our view, however, these variables are insufficient for explaining the root of ethical conflicts. Consequently, the present study formulates a conceptual model that also includes the variable ‘exposure to conflict’, as well as considering six ‘types of ethical conflict’. An instrument (...) was then designed to measure the ethical conflicts experienced by nurses who work with critical care patients. The paper describes the development process and validation of this instrument, the Ethical Conflict in Nursing Questionnaire Critical Care Version (ECNQ-CCV). (shrink)

Background: Moral distress is a major problem in nursing profession. Researchers identified that the stronger the ethical basis of the organization, the less moral distress is reported. However, different ethical climates may have different impacts on moral distress. Moreover, conceptualization of moral distress and ethical climate as well as their relationship may change according to the cultural context. Objectives: The main aim of the study is to investigate the relationship between different types of ethical climate as described in Victor and (...) Cullen’s framework, and moral distress intensity among nurses in Turkish healthcare settings. Research design: An online survey was administrated to collect data. Questionnaires included moral distress and ethical climate scales in addition to demographic questions. Participants and research context: Data were collected from registered nurses in Turkey. In all, 201 of 279 nurses completed questionnaires, resulting in a response rate of 72%. Ethical considerations: Ethical approval was obtained from the university to which the authors were affiliated, after a detailed investigation of the content and data collection method. Findings: Factor analyses showed that moral distress had three dimensions, namely, organizational constraints, misinformed and over-treated patients, and lack of time and resources, while ethical climate had four types, namely, rules, well-being of stakeholders, individualism, and organizational interests. Positive correlations were identified between certain types of ethical climate (rules, individualism, or organizational interests) and moral distress intensity. Discussion: Factor distribution of the scales shows some commonalities with the findings of previous research. However, context-specific dimensions and types were also detected. No particular ethical climate type was found to have a negative correlation with moral distress. Conclusion: Recommendations were made for reducing the negative impact of ethical climate on moral distress. These include solving the nursing-shortage problem, increasing autonomy, and improving physical conditions. (shrink)

The purpose of this article is to report what can be learned about nurses’ ethical conflicts by the systematic analysis of methodologically similar studies. Five studies were identified and analysed for: (1) the character of ethical conflicts experienced; (2) similarities and differences in how the conflicts were experienced and how they were resolved; and (3) ethical conflict themes underlying four specialty areas of nursing practice (diabetes education, paediatric nurse practitioner, rehabilitation and nephrology). The predominant character of the ethical conflicts was (...) disagreement with the quality of medical care given to patients. A significant number of ethical conflicts were experienced as ‘moral distress’, the resolution of which was variable, depending on the specialty area of practice. Ethical conflict themes underlying the specialty areas included: differences in the definition of adequacy of care among professionals, the institution and society; differences in the philosophical orientations of nurses, physicians and other health professionals involved in patient care; a lack of respect for the knowledge and expertise of nurses in specialty practice; and difficulty in carrying out the nurse’s advocacy role for patients. (shrink)

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. (shrink)

Background: Nurse managers are placed in a unique position within the healthcare system where they greatly impact upon the nursing work environment. Ethical dilemmas and moral distress have been reported for staff nurses but not for nurse middle managers. Objective: To describe ethical dilemmas and moral distress among nurse middle managers arising from situations of ethical conflict. Methods: The Ethical Dilemmas in Nursing–Middle Manager Questionnaire and a personal characteristics questionnaire were administered to a convenience sample of middle managers from four (...) hospitals in Israel. Results: Middle managers report low to moderate levels of frequency and intensity of ethical dilemmas and moral distress. Highest scores were for administrative dilemmas. Conclusion: Middle managers experience lower levels of ethical dilemmas and moral distress than staff nurses, which are irrespective of their personal characteristics. Interventions should be developed, studied, and then incorporated into institutional frameworks in order to improve this situation. (shrink)