Nurses' moral strength: a hermeneutic inquiry in nursing practice

Moral courage of emergency nurses in care-limited environments: A mixed-methods study

BACKGROUND

Professional ethics in nursing exist to guide care and allow for decision-making to be patient-centered. In the current medicolegal landscape post-Roe and in light of bans on gender-affirming care, the decision-making processes of emergency nurses in the clinical environment of care as informed by both professional and personal ethics are an important area of inquiry.

AIM

The aim of this study was to examine the contribution of moral courage to decision-making by emergency nurses.

RESEARCH DESIGN

A mixed-methods exploratory sequential approach was used, using a standard demographics form and the Nurses Moral Courage Scale to collect quantitative data. These data were used to inform an interview guide for qualitative data collection. Situational analysis was used to analyze the interview data.

ETHICAL CONSIDERATIONS

Prior to recruitment, this study was reviewed and approved by the University of Massachusetts IRB (#00003909). Participants were provided with an informed consent document at the time of registration and at the time of interview; participants provided both signed consent and verbal assent. Participants were assigned study codes to maintain anonymity and data were maintained in a secure University cloud.

PARTICIPANTS AND RESEARCH CONTEXT

US-based emergency nurses working in environments with care limitations.

RESULTS

70% of respondents reported that they would speak up if they were aware of a situation that was ethically challenging. Respondents reported that it was fairly easy or very easy to defend their values when addressing ancillary staff, coworkers, authorities outside the organization, patients, and patient families. Respondents reported challenges in defending their professional values to charge nurses, physicians, or administrators. In response to a serious ethical problem, 65.8% of respondents answered that they would bring up the problem for discussion, 21.1% would file an internal report, and 13.2% would report externally. Interview participants reported significant social and professional barriers to acting in response to an ethical violation. Willingness to act centered on personal values and not professional codes of ethics.

CONCLUSIONS

While emergency nurses in this study reported high perceived levels of moral courage, they also reported low willingness to act directly, citing burnout and significant social and professional barriers. Adherence to professional codes of ethics is not the primary driver of moral courage.

Moral distress, moral courage, and career identity among nurses: A cross-sectional study

Background

The concept of career identity is integral to nursing practices and forms the basis of the nursing professions. Positive career identity is essential for providing high-quality care, optimizing patient outcomes, and enhancing the retention of health professionals. Therefore, there is a need to explore potential influencing variables, thereby developing effective interventions to improve career identity.

Objectives

To investigate the relationship between moral distress, moral courage, and career identity, and explore the mediating role of moral courage between moral distress and career identity among nurses.

Design

A quantitative, cross-sectional study.

Methods

A convenient sample of 800 nurses was recruited from two tertiary care hospitals between February and March 2022. Participants were assessed using the Moral Distress Scale-revised, Nurses’ Moral Courage Scale, and Nursing Career Identity Scale. This study was described in accordance with the STROBE statement.

Ethical consideration

Research ethics approval was obtained from the researcher’s university and hospital where this study was conducted prior to data collection.

Findings

Moral distress is negatively associated while moral courage is positively associated with career identity among nurses. Moral courage partially mediates the relationship between moral distress and career identity ( β = −0.230 to −0.163, p < 0.01).

Discussion

The findings reveal a relationship between moral distress, moral courage, and career identity among nurses.

Conclusion

By paying attention to nurses’ moral distress and courage, healthcare providers can contribute to the development of effective interventions to improve career identity, and subsequently performance, among nurses.

Whistle-blowers - morally courageous actors in health care?

BACKGROUND

Moral courage means courage to act according to individual's own ethical values and principles despite the risk of negative consequences for them. Research about the moral courage of whistle-blowers in health care is scarce, although whistleblowing involves a significant risk for the whistle-blower.

OBJECTIVE

To analyse the moral courage of potential whistle-blowers and its association with their background variables in health care.

RESEARCH DESIGN

Was a descriptive-correlational study using a questionnaire, containing Nurses Moral Courage Scale©, a video vignette of the wrongdoing situation with an open question about the vignette, and several background variables. Data were analysed statistically and inductive content analysis was used for the narratives.

PARTICIPANTS AND RESEARCH CONTEXT

Nurses as healthcare professionals (including registered nurses, public health nurses, midwives, and nurse paramedics) were recruited from the membership register of the Nurses' Association via email in 2019. A total of 454 nurses responded. The research context was simulated using a vignette.

ETHICAL CONSIDERATIONS

Good scientific inquiry guidelines were followed. Permission to use the Nurses' Moral Courage Scale© was obtained from the copyright holder. The ethical approval and permission to conduct the study were obtained from the participating university and the Nurses' Association.

FINDINGS

The mean value of potential whistle-blowers' moral courage on a Visual Analogue Scale (0-10) was 8.55 and the mean score was 4.34 on a 5-point Likert scale. Potential whistle-blowers' moral courage was associated with their socio-demographics, education, work, personality and social responsibility related background variables.

DISCUSSION AND CONCLUSION

In health care, potential whistle-blowers seem to be quite morally courageous actors. The results offer opportunities for developing interventions, practices and education to support and encourage healthcare professionals in their whistleblowing. Research is needed for developing a theoretical construction to eventually increase whistleblowing and decrease and prevent wrongdoing.

Validation of the Dutch-language version of Nurses' Moral Courage Scale

BACKGROUND

Moral courage as a part of nurses' moral competence has gained increasing interest as a means to strengthen nurses acting on their moral decisions and offering alleviation to their moral distress. To measure and assess nurses' moral courage, the development of culturally and internationally validated instruments is needed.

OBJECTIVE

The objective of this study was to validate the Dutch-language version of the four-component Nurses' Moral Courage Scale originally developed and validated in Finnish data.

RESEARCH DESIGN

This methodological study used non-experimental, cross-sectional exploratory design.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 559 nurses from two hospitals in Flanders, Belgium, completed the Dutch-language version of the Nurses' Moral Courage Scale.

ETHICAL CONSIDERATIONS

Good scientific inquiry guidelines were followed throughout the study. Permission to translate the Nurses' Moral Courage Scale was obtained from the copyright holder, and the ethical approval and permissions to conduct the study were obtained from the participating university and hospitals, respectively.

FINDINGS

The four-component 21-item, Dutch-language version of the Nurses' Moral Courage Scale proved to be valid and reliable as the original Finnish Nurses' Moral Courage Scale. The scale's internal consistency reliability was high (0.91) corresponding with the original Nurses' Moral Courage Scale validation study (0.93). The principal component analysis confirmed the four-component structure of the original Nurses' Moral Courage Scale to be valid also in the Belgian data explaining 58.1% of the variance. Confirmatory factor analysis based on goodness-of-fit indices provided evidence of the scale's construct validity. The use of a comparable sample of Belgian nurses working in speciality care settings as in the Finnish study supported the stability of the structure.

DISCUSSION AND CONCLUSION

The Dutch-language version of the Nurses' Moral Courage Scale is a reliable and valid instrument to measure nurses' self-assessed moral courage in speciality care nursing environments. Further validation studies in other countries, languages and nurse samples representing different healthcare environments would provide additional evidence of the scale's validity and initiatives for its further development.

Moral courage in nursing - An integrative literature review

Moral courage and understanding of its meaning are essential when nurses face ethical conflicts in their practice. This integrative review aimed to explore moral courage in nursing and possible associated individual and organizational factors. A database search in January 2020 identified 1308 scientific articles of which 25 were selected for the review. Inductive analysis with clear steps for defining and synthesizing themes in research reviews revealed three categories concerning moral courage in nursing: definition and descriptions of moral courage, characteristics of the morally courageous nurse, and skills and acts of the morally courageous nurse. Individual and organizational factors, such as positive personal experiences, commitment to ethical principles, supportive work environment and teamwork, were associated with moral courage in nursing, contributing to a more comprehensive description of nurses' moral courage. Findings indicate that in nursing practice, there is a need for promoting multi-professional collaboration and discussion of ethical dilemmas to provide opportunities to enhance moral courage. Developing care environments in which hierarchy does not inhibit nurses' moral courage seems justified. Further research on moral courage with varying methodologies and multi-disciplinary and international approaches is needed.

Care situations demanding moral courage: Content analysis of nurses’ experiences

Background:

Nurses encounter complex ethical dilemmas in everyday nursing care. It is important for nurses to have moral courage to act in these situations which threaten patients’ safety or their good care. However, there is lack of research of moral courage.

Purpose:

This study describes nurses’ experiences of care situations demanding moral courage and their actions in these situations.

Method:

A qualitative descriptive research design was applied. The data were collected with an open-ended question in the questionnaire used in validation of the Nurses’ Moral Courage Scale. The sample consisted of 286 nurses from four different clinical fields in a major university hospital in Finland, providing a total of 611 answers. Data were analyzed using inductive content analysis.

Ethical considerations:

The study followed the commonly recognized principles of good scientific practice. The use of data was authorized by the developer of the instrument, the data collector, and the participating hospital. Ethical approval was obtained from the university ethics committee.

Findings:

Nurses acted morally courageously in most situations but sometimes they failed to do so. Although situations demanding moral courage varied, they could be categorized into seven main domains relating to colleagues, physicians, patients, relatives, nurses themselves, managers, and organizations. Nurses acted in the situations in different ways. The main acts in solving the situations were verbal communication or immediate action, such as interrupting of action.

Conclusion:

Care situations demanding moral courage focus on good and safe patient care and the patient’s good is at the center of attention. The situations are mostly related to the activities of other healthcare professionals. Findings may be applied in developing ethical nursing care through basic and continuing nursing education. Research is needed on the moral courage of physicians and managers, as well as on patients’ and their relatives’ experiences of care situations demanding moral courage.

A latent profile analysis of nurses' moral sensitivity

BACKGROUND

The three-dimensional model of nurses' moral sensitivity has typically been studied using a variable-centered rather than a person-centered approach, preventing a more complete understanding of how these forms of moral sensitivity are expressed as a whole. Latent profile analysis is a person-centered approach that classifies individuals from a heterogeneous population into homogeneous subgroups, helping identify how different subpopulations of nurses use distinct combinations of different moral sensitivities to affect their service behaviors.

OBJECTIVE

Latent profile analysis was used to identify three distinct profiles of nurses' moral sensitivity. Associations of the profiles with service behaviors were then examined.

METHODS

Five hundred twenty-five nurses from three tertiary hospitals in China were investigated with Moral Sensitivity Questionnaire and Nurses' Service Behavior Scale. Latent profile analysis was used to analyze the data.

ETHICAL CONSIDERATIONS

Approval was obtained from the Ethics committee for biomedical research of Medical College, the Hebei University of Engineering.

RESULTS

A three-profile moral sensitivity model provided the best fit to the data. The resulting profiles were low moral sensitivity, moderate moral sensitivity, and high moral sensitivity. There were significant differences in service behaviors among different profiles of moral sensitivity.

CONCLUSION

The results provide a new and expanded view of nurses' moral sensitivity, which may be used to monitor nurses' service behaviors comprehensively and to evaluate nursing ethics management strategies.

Encountering existential loneliness among older people: perspectives of health care professionals

PURPOSE

Existential loneliness is part of being human that is little understood in health care, but, to provide good care to their older patients, professionals need to be able to meet their existential concerns. The aim of this study was to explore health care professionals' experiences of their encounters with older people they perceive to experience existential loneliness.

METHOD

We conducted 11 focus groups with 61 health professionals working in home care, nursing home care, palliative care, primary care, hospital care, or pre-hospital care. Our deductive-inductive analytical approach used a theoretical framework based on the work of Emmy van Deurzen in the deductive phase and an interpretative approach in the inductive phase.

RESULTS

The results show that professionals perceived existential loneliness to appear in various forms associated with barriers in their encounters, such as the older people's bodily limitations, demands and needs perceived as insatiable, personal shield of privacy, or fear and difficulty in encountering existential issues.

CONCLUSION

Encountering existential loneliness affected the professionals and their feelings in various ways, but they generally found the experience both challenging and meaningful.

Development and validation of Nurses' Moral Courage Scale

BACKGROUND

Moral courage is required at all levels of nursing. However, there is a need for development of instruments to measure nurses' moral courage.

OBJECTIVES

The objective of this study is to develop a scale to measure nurses' self-assessed moral courage, to evaluate the scale's psychometric properties, and to briefly describe the current level of nurses' self-assessed moral courage and associated socio-demographic factors.

RESEARCH DESIGN

In this methodological study, non-experimental, cross-sectional exploratory design was applied. The data were collected using Nurses' Moral Courage Scale and analysed statistically.

PARTICIPANTS AND RESEARCH CONTEXT

The data were collected from a convenience sample of 482 nurses from four different clinical fields in a major university hospital in Finland for the final testing of the scale. The pilot comprised a convenience sample of 129 nurses.

ETHICAL CONSIDERATIONS

The study followed good scientific inquiry guidelines. Ethical approval was obtained from the university ethics committee and permission to conduct the study from the participating hospital.

FINDINGS

Psychometric evaluation showed that the 4-sub-scale, 21-item Nurses' Moral Courage Scale demonstrates good reliability and validity at its current state of development showing a good level of internal consistency for a new scale, the internal consistency values ranging from 0.73 to 0.82 for sub-scales and 0.93 for the total scale, thus well exceeding the recommended Cronbach's alpha value of >0.7. Principal component analysis and confirmatory factor analysis supported the theoretical construct of Nurses' Moral Courage Scale. Face validity and expert panel assessments markedly contributed to the relevance of items in establishing content validity.

DISCUSSION AND CONCLUSION

Nurses' Moral Courage Scale provides a new generic instrument intended for measuring nurses' self-assessed moral courage. Recognizing the importance of moral courage as a part of nurses' moral competence and its assessment offers possibilities to develop interventions and educational programs for enhancement of moral courage. Research should focus on further validation measures of Nurses' Moral Courage Scale in international contexts.

Is privacy a problem during bedside handovers? A practice-oriented discussion paper

Bedside handover is the delivery of the nurse-to-nurse handover at the patient’s bedside. Although increasingly used in nursing, nurses report many barriers for delivering the bedside handover. Among these barriers is the possibility of breaching the patient’s privacy. By referring to this concept, nurses add a legal and ethical dimension to the delivery of the bedside handover, making implementation of the method difficult or even impossible. In this discussion article, the concept of privacy during handovers is being discussed by use of observations, interviews with nurses, and interviews with patients. These findings are combined with international literature from a narrative review on the topic. We provide a practice-oriented answer in which two mutually exclusive possibilities are discussed. If bedside handover does pose problems concerning privacy, this situation is not unique in healthcare and measures can be taken during the bedside handover to safeguard the patient. If bedside handover does not pose problems concerning privacy, privacy is misused by nurses to hide professional uncertainties and/or a reluctance toward patient participation. Therefore, a possible breach of privacy—whether a justified argument or not—is not a reason for not delivering the bedside handover.

Concept analysis of moral courage in nursing: A hybrid model

BACKGROUND

Moral courage is one of the most fundamental virtues in the nursing profession, however, little attention has been paid to it. As a result, no exact and clear definition of moral courage has ever been accessible.

OBJECTIVE

This study is carried out for the purposes of defining and clarifying its concept in the nursing profession.

METHODS

This study used a hybrid model of concept analysis comprising three phases, namely, a theoretical phase, field work phase, and a final analysis phase. To find relevant literature, electronic search of valid databases was utilized using keywords related to the concept of courage. Field work data were collected over an 11 months' time period from 2013 to 2014. In the field work phase, in-depth interviews were performed with 10 nurses. The conventional content analysis was used in two theoretical and field work phases using Graneheim and Lundman stages, and the results were combined in the final analysis phase. Ethical consideration: Permission for this study was obtained from the ethics committee of Tehran University of Medical Sciences. Oral and written informed consent was received from the participants.

RESULTS

From the sum of 750 gained titles in theoretical phase, 26 texts were analyzed. The analysis resulted in 494 codes in text analysis and 226 codes in interview analysis. The literature review in the theoretical phase revealed two features of inherent-transcendental characteristics, two of which possessed a difficult nature. Working in the field phase added moral self-actualization characteristic, rationalism, spiritual beliefs, and scientific-professional qualifications to the feature of the concept.

CONCLUSION

Moral courage is a pure and prominent characteristic of human beings. The antecedents of moral courage include model orientation, model acceptance, rationalism, individual excellence, acquiring academic and professional qualification, spiritual beliefs, organizational support, organizational repression, and internal and external personal barriers. Professional excellence resulting from moral courage can be crystallized in the form of provision of professional care, creating peace of mind, and the nurse's decision making and proper functioning.

Moral courage in nursing: A concept analysis

BACKGROUND

Nursing as an ethical practice requires courage to be moral, taking tough stands for what is right, and living by one's moral values. Nurses need moral courage in all areas and at all levels of nursing. Along with new interest in virtue ethics in healthcare, interest in moral courage as a virtue and a valued element of human morality has increased. Nevertheless, what the concept of moral courage means in nursing contexts remains ambiguous.

OBJECTIVE

This article is an analysis of the concept of moral courage in nursing.

DESIGN

Rodgers' evolutionary method of concept analysis provided the framework to conduct the analysis.

DATA SOURCES

The literature search was carried out in September 2015 in six databases: PubMed, CINAHL, Scopus, Web of Science, PsycINFO, and The Philosopher's Index. The following key words were used: "moral" OR "ethical" AND "courage" OR "strength" AND "nurs*" with no time limit. After applying inclusion and exclusion criteria, 31 studies were included in the final analysis. Ethical considerations: This study was conducted according to good scientific guidelines.

RESULTS

Seven core attributes of moral courage were identified: true presence, moral integrity, responsibility, honesty, advocacy, commitment and perseverance, and personal risk. Antecedents were ethical sensitivity, conscience, and experience. Consequences included personal and professional development and empowerment.

DISCUSSION AND CONCLUSION

This preliminary clarification warrants further exploring through theoretical and philosophical literature, expert opinions, and empirical research to gain validity and reliability for its application in nursing practice.

Integrity and mental health nursing: factors to consider

Integrity is interpreted as a holistic phenomenon that incorporates personal characteristics, cognition, interpersonal awareness, and practical enactment-ultimately relating to matters society deems worthwhile. This approach enables integrity to be understood as both a personal morality and a social (group) morality. Mental health nurses embedded in a hierarchical bureaucratic organisation may act according to their personal morality and display moral strength in many situations; however, if the social morality of the group is at variance with their convictions, as individuals their capacity to be courageous and enact integrity will be tested. A likely consequence will be that those with the most cherished positive patient care values, those with a stronger adherence to moral convictions about the public good, and those with a clearly developed understanding of integrity parameters will depart, and possibly leave the profession. In this article, we provide an overview of the structural and contextual realities of nursing work within organisations and discuss how these factors can compromise whole unit integrity and seriously challenge mental health nurses' commitment to enacting integrity. In the final section of this article, broad suggestions for strengthening individual and group integrity are provided.

Failing a student nurse: a new horizon of moral courage

The factors preventing registered nurses from failing students in practice are multifaceted and have attracted much debate over recent years. However, writers rarely focus on what is needed to fail an incompetent pre-registration nursing student in their final placement. This hermeneutic study explored the mentor experience of failing a pre-registration nursing student in their final placement. A total of 19 mentors were recruited from 7 different healthcare organisations in both inner city and rural locations in the southeast of England. Participants took part in individual reflective interviews about their experience of failing a pre-registration nursing student in their final placement. These experiences were interpreted through a hermeneutic discovery of meaning. The new horizon of understanding which developed as a result of this research is framed within the context of moral stress, moral integrity and moral residue with the overall synthesis being that these mentors' stories presented a new horizon of moral courage.

Nursing's role in courage development in patients facing complications of diabetes

The purpose of this study was to explore the experience of nurses in relation to courage development in patients with disabling complications of diabetes. The phenomenon of courage has been explored in philosophy, theology, literature, and other fields of inquiry rooted in the humanities. Nursing inquiry has not often been directed toward an exploration of courage, although coping, compassion, caring, and other experiences integral to the nurse-patient relationship have been examined. The holistic view of the cascading effect of complications on the individual patient is often overlooked. This qualitative study used phenomenological inquiry and included face-to-face interviews of nurses to explore their experience in assisting patients in the development of courage. The experience of courage is investigated as it relates to a specific group of patients who have complications of diabetes. Four categories representing the unique opportunities for courage development by nurses were generated. These categories included education, advocacy, relationship building, and humanization. Each category described nursing intentions and actions and taken together formed an essential structure of courage development. Conclusions indicated that nurses recognize and are able to describe their role in courage development. Implications for improved health through deliberate caring nursing interventions, aimed at courage development, are presented.

The impact of clinical encounters on student nurses' ethical caring

The aim of this study was to get a deeper understanding of student nurses' experiences of personal caring ethics by reflection on caring encounters with patients in clinical practice, ethical caring ideals, ethical problems, and sources for inner strength that give courage to practice good caring. In all, 24 Scandinavian student nurses participated voluntarily in an interview study. The interviews were analyzed within a phenomenological-hermeneutical approach and revealed three themes. The students found themselves in two different states of vulnerability: one in which they were overwhelmed by their vulnerability and began to suffer themselves and the other where their vulnerability became a source of development with focus on the patient. The students' ethical caring ideals served as fixed reference points in their ethical development, but their ideals were at risk of decline. The students reflected on the barriers for performing ethical care and nurtured their ethical ideals by providing ethical care in secret. Caring in secret occurred also when student nurses did not experience a shared ethos.

Ethical problems: In the face of sudden and unexpected death

When people die suddenly and unexpectedly ethical issues often come to the fore. The aim of the study was to describe experiences of members of stroke teams in stroke units of ethical problems and how the teams manage the situation when caring for patients faced with sudden and unexpected death from stroke. Data were collected through four focus group interviews with 19 team members in stroke-unit teams, and analysed using interpretive content analysis. Three themes emerged from the analysis characterized by information, decisions about care and support for the next-of-kin in the changing and uncertain situation, with mutual trust as the core. Mutual trust, both within the stroke team and with next-of-kin was seen by the stroke-team members as a way of handling ethical problems by administering care with the patient’s best interest at heart.

Evaluation of the Manchester clinical supervision scale: Norwegian and Swedish versions

AIM

To develop Norwegian and Swedish versions of the Manchester Clinical Supervision Scale (MCSS) and to test and verify its hypothesized seven-factor structural model.

BACKGROUND

Nurse managers are responsible for upholding and ensuring quality of care as well as for maintaining staff competence, thus safeguarding the standard of care.

METHODS

The research process included a translation-back-translation procedure with monolingual and bilingual tests in addition to psychometric evaluation. The sample consisted of 150 student and registered nurses (RNs) from Norway and Sweden, and confirmatory factor analysis was performed.

RESULTS

The translated versions did not exhibit satisfactory validity and reliability. The confirmatory factor analysis failed to show a good model fit. Low α-values were revealed except for factors 1, 2, 3 and 7. The most important factors of the MCSS were Trust/Rapport, Supervisor advice/Support, Improved care/Skills and Reflection.

CONCLUSION

Translation of an instrument for cross-cultural nursing research is important, although there are methodological limitations associated with construct validity. IMPLICATION FOR NURSE MANAGERS: Instruments for the evaluation of nursing care are necessary in order to formulate strategies at a managerial level. Nurse managers who encourage nurses to attend supervision promote professional development and enhance patient safety.

Corroborating indicates nurses' ethical values in a geriatric ward

The aim of the study was to identify nurses' ethical values, which become apparent through their behaviour in the interactions with older patients in caring encounters at a geriatric clinic.Descriptions of ethics in a caring practice are a problem since they are vague compared with the four principles of autonomy, beneficence, non-maleficence, and justice.A Grounded Theory methodology was used. In total, 65 observations and follow-up interviews with 20 nurses were conducted, and data were analysed by constant comparative analysis.THREE CATEGORIES WERE IDENTIFIED: showing consideration, connecting, and caring for. These categories formed the basis of the core category: "Corroborating." In corroborating, the focus is on the person in need of integrity and self-determination; that is, the autonomy principle. A similar concept was earlier described in regard to confirming. Corroborating deals more with support and interaction. It is not enough to be kind and show consideration (i.e., to benefit someone); nurses must also connect and care for the older person (i.e., demonstrate non-maleficence) in order to corroborate that person.The findings of this study can improve the ethics of nursing care. There is a need for research on development of a high standard of nursing care to corroborate the older patients in order to maintain their autonomy, beneficence, and non-maleficence. The principal of justice was not specifically identified as a visible nursing action. However, all older patients received treatment, care, and reception in an equivalent manner.

Early indicators and risk factors for ethical issues in clinical practice

PURPOSE

Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify risk factors and early indicators of ethical conflicts.

METHODS

Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, their risk factors and early indicators, nurse actions, and situational outcomes. Two nurse researchers independently analyzed and categorized data using a constant comparison technique.

FINDINGS

Most of the ethically difficult situations pertained to end-of-life care for children and adults. Conflicts in interpersonal relationships were prevalent. Nurses were especially moved by patient and family suffering and concerned about patient vulnerability, harm-benefit ratio, and patient autonomy. Researchers discovered risk factor categories for patients, families, healthcare providers, and health systems. Additionally, researchers found subcategories in six major categories of early indicators: signs of conflict, patient suffering, nurse distress, ethics violation, unrealistic expectations, and poor communication.

CONCLUSIONS

Nurses are keenly aware of pertinent risk factors and early indicators of unfolding ethical conflicts. Many nurses reported feeling powerless in the face of ethical conflict. Research that develops interventions to strengthen nurses' voices in ethically difficult situation is warranted.

CLINICAL RELEVANCE

Nurses are in a key position to identify patient situations with a high risk for ethical conflict. Initiating early ethics consultation and interventions can alter the course of pending conflicts and diminish the potential for patient and family suffering and nurses' moral distress.

Fear of childbirth: mothers' experiences of team-midwifery care - a follow-up study

AIM

The aim of this study was to illuminate mothers' fear of childbirth and their experiences of the team-midwifery care model during pregnancy, childbirth and the postnatal period.

BACKGROUND

Maternal anxiety and fear of childbirth lead to emotional suffering and affected women's well-being. A previous negative experience of childbirth may result in postnatal depression or avoidance of future pregnancies.

METHODS

This hermeneutic study comprised interviews with 13 women, which were audio-taped and transcribed verbatim, after which interpretative content analysis was performed. Ethical approval was granted.

RESULTS

The findings revealed one main theme: The woman's right to ownership of the pregnancy, childbirth and postnatal care as a means of maintaining dignity and three themes; Being aware of barriers and reasons for fear; Being prepared for childbirth and Being confirmed and treated with dignity by the midwife. Each theme contained several sub-themes.

CONCLUSION

The findings contribute insights into how midwives can be educated to reduce fear of childbirth and promote positive birth experiences, despite the existence of negative memories of previous births.

IMPLICATION FOR NURSING MANAGEMENT

In order to achieve continuity and a trusting relationship it is necessary to organise leadership and to adopt models that are flexible and support women's health.

The meaning of guilt and shame: a qualitative study of mothers who suffer from eating difficulties

The aim of this study was to illuminate and interpret guilt and shame expressed by mothers with eating difficulties (ED). The research question was: What is the meaning of guilt and shame experienced by mothers with ED? Experiences of guilt and shame in mothers with ED may be strong, yet concealed, and should be addressed when promoting women's mental health. The study design was explorative, and in-depth interviews were conducted with eight mothers suffering from ED. The data were analysed by means of qualitative content analysis and interpreted according to a hermeneutic approach. The main theme 'Struggling in silence with guilt and shame as a mother living with ED and trying to keep it secret' was interpreted on two levels: emotional, 'Feeling worried about failure and wanting to be successful', and cognitive, 'Having condemning thoughts about one's own sense of responsibility'. In addition, each theme contained two subthemes. Feelings and awareness of guilt and shame are strong; they vary between individuals and are intensified in mothers who suffer from ED. It is important for mental health nurses to help mothers with ED articulate such feelings in order to promote health.