Concept analysis of conscience-based nursing care: a hybrid approach of Schwartz-Barcott and Kim's hybrid model

BACKGROUND

The nursing profession considers conscience as the foundation and cornerstone of clinical practice, which significantly influences professional decision-making and elevates the level of patient care. However, a precise definition of conscience in the nursing field is lacking, making it challenging to measure. To address this issue, this study employed the hybrid approach of Schwartz Barcott and Kim to analyze the concept of conscience-based nursing care.

METHODS

This approach involves a three-phase process; theoretical, fieldwork, and analytical. A systematic literature review was conducted using electronic databases during the first phase to find relevant papers. The content of 42 articles that met the inclusion criteria was extracted to determine the attributes, antecedents, and consequences of consciousness care using thematic analysis. Based on the working definition as a product of this phase, the plan of doing the fieldwork phase was designed. During this phase, data were collected through interviews with nurses all of whom were responsible for patient care in hospitals. In this phase, 5 participants were chosen for in-depth interviewing by purposeful sampling. Data were analyzed using directed content analysis. The findings of the theoretical and fieldwork phases were integrated and the final definition was derived.

RESULTS

The integration of the theoretical and fieldwork phases resulted in identifying four key characteristics of conscience-based nursing care. Firstly, it involves providing professional care with a conscientious approach. Secondly, ethics is at the core of conscience-based care. Thirdly, external spirituality plays a significant role in shaping one's conscience in this context. Finally, conscience-based nursing care is both endogenous and exogenous, with professional commitment being the central focus of care.

CONCLUSION

Conscience-based nursing care is an essential component of ethical care, which elevates clinical practice to professional care. It requires the integration of individual and social values, influenced by personal beliefs and cultural backgrounds, and supported by professional competence, resources, and a conducive organizational atmosphere in the healthcare field. This approach leads to the provision of responsive care, moral integrity, and individual excellence, ultimately culminating in the development of professionalism in nursing.

The effect of conscience perception on job satisfaction and care behaviours in nurses

Conscience is a force capable of making judgments about one's own moral values during individual behaviour. Conscience in nursing is a concept that is perceived as authority and an inner voice, and it positively affects nursing care. Today, according to many research results, conscience is an indicator of professionalism that affects our personal and professional lives. This research was carried out to determine the effect of nurses' perceptions of conscience on job satisfaction and care behaviours. A cross-sectional study was performed in a training and research hospital. The sample size of 338 nurses was determined by power analysis, and the participants were selected using a simple random sampling method. The data were collected between June and November 2020. A "Personal Information Form", the "Conscience Perception Scale (CPS)", the "Nurse Job Satisfaction Scale (NJSS)" and the "Caring Behaviours Scale-30 (CBS-30)" were used to collect the data. The nurses obtained a score of 63.36 ± 12.13 on the CPS, indicating a high level of conscience perception; a total of 3.41 ± 0.69 points on the NJSS, revealing a high level of job satisfaction; and a total of 150.42 ± 21.22 points on the CBS-30, implying that care perceptions were found to be high. It was determined that the nurses' perceptions of conscience had an effect on their job satisfaction and care behaviours (R = 0.398, Adjusted R2 = 0.158, p = 0.000). The nurses who participated in the study had a high perception of conscience, which positively affected their job satisfaction and care behaviours.

Perceptions and stress of conscience in relation to burnout among nursing staff in older people care settings: a cross sectional study

BACKGROUND

Considering cultural influences, it is important to study the perceptions and stress of conscience in different contexts. This study aimed to investigate the association between perceptions of conscience, stress of conscience, and burnout among nursing staff working in older people care settings in Tehran.

METHODS

This was a descriptive, cross-sectional study. A total of 161 participants completed the Perceptions of Conscience Questionnaire, Stress of Conscience Questionnaire, and Oldenburg Burnout Inventory, 2019. All nursing staff working at the 20 contacted nursing homes agreed to participate in the study. The descriptive and inferential analysis was conducted through SPSS, using T-tests and one-way between-groups analysis of variance, Chi-square and t-tests, Cohen's d (d), Eta-squared (η2), and Phi coefficient (φ), Partial least squares regression (PLSR), jackknife approximate t-tests of the regression coefficients, and jackknife 95% confidence intervals of the regression coefficients.

RESULTS

The nursing staff perceived their conscience mainly as an authority, asset, and warning signal. Impact of workload on family life was the most common source of stress for the nursing staff. Dealing with incompatible demands, the impact of workload on family life, witnessing insulated patients, inability to meet one's standards in providing care, and perception of conscience as a burden were strongly associated with the burnout.

CONCLUSIONS

Perceiving conscience as a warning signal or authority may serve as a buffer against burnout among nursing staff. This study highlights the need for further exploration of perceptions of conscience in different cultural and social backgrounds.

Striving to Keep a Clear Conscience by Going Above and Beyond: The Experiences of Intensive Care Unit Nurses

Working as a nurse in the critical care unit may involve ethical challenges including conflict of conscience. Literature provides very limited knowledge about intensive care unit (ICU) nurses' perception of conscience. Considering the influence of culture on the perception of conscience, it is important to study it in diverse contexts. This study aims were to explore the meaning of conscience and the impact of conscience on nurses' practice in the ICU. A qualitative research approach was used to answer the research question, and qualitative content analysis guided the study. A total of 17 interviews were conducted with ICU nurses. Data were collected through semistructured tools by using videoconferencing and face-to-face interviews. Data analysis resulted in the formation of 2 main categories and 7 subcategories. The main categories included understanding the conscience and unlimited efforts in caretaking as the path to a clear conscience. The category of understanding the conscience includes 3 subcategories of conscience as an intrinsic asset and internal observer, dynamicity of conscience, and conscience as the cornerstone of morality. Also, the category of unlimited efforts in caretaking as the path to a clear conscience consists of 4 subcategories including giving full attention to the patient, putting oneself in another's shoes, taking responsibility, and working beyond the job description. Conscience plays an essential role in providing the ethical care among ICU nurses. The ICU nurses felt that they need to go above and beyond to keep their conscience clear. Nurses expressed the importance of following the call of conscience at their workplace, which demanded unlimited efforts to achieve a clear conscience.

Meanings of troubled conscience in nursing homes: nurses' lived experience

BACKGROUND

Troubled conscience among nurses and other healthcare workers represents a significant contributor to healthcare worker moral distress, burnout and attrition. While research in this area has examined critical care in hospitals, less knowledge has been obtained from long-term care contexts such as nursing homes, despite widely recognised challenges with regard to vulnerable patients, increasing workload and maintaining workforce sustainability among nurses.

OBJECTIVE

The aim of this study was to illuminate and interpret the meaning of the lived experience of troubled conscience among registered nurses (RNs) working in nursing homes.

RESEARCH DESIGN

This qualitative research employed narrative interviews with eight nurses to obtain essential meanings of their lived experiences of troubled conscience. The interview texts were analysed using a phenomenological hermeneutic approach.

ETHICAL CONSIDERATIONS

Participation was voluntary, informed and was conducted with written consent. The Norwegian Centre for Research Data approved the data processing of personal data.

FINDINGS

The analysis uncovered two themes: (1) troubled conscience means abandoning ideals, with the subthemes: failing dependent patients; being disloyal to colleagues; being inadequate in the performance of work tasks and (2) troubled conscience means facing realities, with the subthemes: accepting being part of the system; responding to barriers.

DISCUSSION

Troubled conscience meant experiencing continuous and simmering tension between one's ideals and realities and feeling a drive to preserve accountability and one's moral integrity. Endangered ideals were often under cross-pressure and included humanistic values, professional values, working life values and the values of the organisation.

CONCLUSION

Nurses' troubled conscience refers to a struggle, but also a force that plays out at various levels and arenas in long-term care. Openness and dialogue about how professional values and the welfare state's intentions can be realised within the given framework are important for individual nurses' occupational health as well as the quality of care provided to patients.

The psychiatric mental health nurse's ethical considerations regarding the use of coercive measures - a qualitative interview study

BACKGROUND

In psychiatric inpatient care, situations arise where it may be necessary to use coercive measures and thereby restrict individual autonomy. The ethical principles of healthcare, i.e., respect for autonomy, beneficence, nonmaleficence, and justice, are recognized as central aspects in healthcare practice, and nurses must be clear about which ethical theories and principles to prioritize and what values are needed for a thorough ethical consideration. The aim of this study is to shed light on psychiatric mental health nurses' ethical considerations and on the factors influencing them when performing coercive measures.

METHODS

This qualitative interview study included twelve psychiatric mental health nurses with experience from psychiatric inpatient care. A content analysis was made. The interviews were audio recorded and transcribed verbatim, and categories were formulated.

RESULTS

The study revealed a duality that created two categories: Ethical considerations that promote the patient's autonomy and health and Obstacles to ethical considerations. Based on this duality, ethical considerations were made when performing coercive measures to alleviate suffering and promote health. The result shows a high level of ethical awareness in clinical work. However, a request emerged for more theoretical knowledge about ethical concepts that could be implemented among the staff.

CONCLUSION

The psychiatric mental health nurses in this study strive to do what is best for the patient, to respect the patient's autonomy as a guiding principle in all ethical considerations, and to avoid coercive measures. An organizational ethical awareness could increase the understanding of the difficult ethical considerations that nurses face with regard to minimizing the use of coercive measures in the long run.

Have we been able to improve the conscientious intelligence levels of nursing students sufficiently?

PURPOSE

This study was aimed at comparing the conscientious intelligence levels of nursing students and determining the factors affecting their conscientious intelligence.

DESIGN AND METHODS

Two hundred and forty nursing students were involved in the study.

FINDINGS

There were no statistically significant differences between the first and fourth-year students in terms of the mean scores they obtained from the compassion, responsibility toward the creator, conscious awareness, and social sensitivity sub-dimensions. Of the students, those who chose the profession willingly, those who were women and those who did not perceive nursing as a profession just to earn money obtained higher mean scores in the Conscientious Intelligence Scale.

PRACTICE IMPLICATIONS

The results of the study revealed that Nurse Academics should make more attempts to improve students' conscientious intelligence.

Stress of conscience and burnout among nurses in Turkey

PURPOSE

To investigate the validity and reliability of the Turkish version of the Stress of Conscience Questionnaire (SCQ) and to determine its relationship to burnout among Turkish nurses.

DESIGN AND METHODS

The sample of this study with a cross-sectional design comprised 375 nurses. The data were collected using the Maslach Burnout Inventory (MBI) and SCQ.

FINDINGS

The mean score of the nurses obtained from the overall SCQ was 85.36 ± 39.3 (min: 0; max: 225). The highest scored item by the nurses was related to "lack of energy to devote themselves to their families." There was a significant positive correlation between the Emotional Exhaustion-MBI scores and SCQ scores (r = 0.414, p < 0.001).

PRACTICE IMPLICATIONS

The Turkish version of SCQ is a valid and reliable tool among Turkish nurses and is associated with emotional exhaustion.

The relationship between ethical leadership, conscientiousness, and moral courage from nurses' perspective

Background

Nurses’ conscientiousness and moral courage are essential to providing high quality care. Leadership is one of the factors that may be very effective in strengthening these characteristics in nurses. Among leadership styles, the ethical leadership has a special value. This study investigated the relationship between ethical leadership of nursing managers, conscientiousness, and moral courage from the nurses’ perspective.

Methods

In this cross-sectional descriptive study, 180 nurses working in hospitals of Yazd, central Iran, were selected through simple random sampling. Three questionnaires: the “Ethical Leadership”, “Conscientiousness”, and “Moral Courage” were used to collect data. Data were analyzed with SPSS20 using descriptive and analytical statistics.

Results

There was a positive and significant relationship between conscientiousness and moral courage with ethical leadership from the nurses’ perspective (P < 0.05). The relationship between conscientiousness and moral courage was also significant (P < 0.05). The regression analysis showed that ethical leadership can be considered as a predictor of conscientiousness and moral courage.

Conclusion

The relationship between ethical leadership and conscientiousness and moral courage suggests that nursing managers, by adopting such an approach in leadership, can increase conscientiousness and moral courage in nurses.

Nurses' attitudes toward, perceptions of, and experiences with conscientious objection

BACKGROUND

Conscientious objection is a person's refusal to fulfill a legal duty due to their ethical values, religious beliefs, or ideological affiliations. In nursing, it refers to a nurse's refusal to perform an action or participate in a particular situation based on their conscience. Conscientious objection has become a highly contested topic in recent years.

RESEARCH OBJECTIVES

This study had four objectives: (1) eliciting information on how Turkish nurses perceive conscientious objection, (2) revealing whether their moral beliefs affect the care they provide, (3) determining their experiences with conscientious objection, and (4) identifying existing or potential issues of conscientious objection.

RESEARCH DESIGN

This qualitative study collected data through semi-structured interviews. The data were analyzed using thematic content analysis.

PARTICIPANTS

The sample consisted of 21 nurses.

ETHICAL CONSIDERATIONS

The study was approved by an ethics committee. Confidentiality and anonymity were guaranteed. Participation was voluntary.

FINDINGS

The analysis revealed four themes: (1) universal values of nursing (professional values), (2) experiences with conscientious objection (refusing to provide care/not providing care), (3) possible effects of conscientious objection (positive and negative), and (4) scope of conscientious objection (grounded and groundless).

CONCLUSION

Participants did not want to provide care due to (1) patient characteristics or (2) their own religious and moral beliefs. Participants stated that conscientious objection should be limited in the case of moral dilemmas and accepted only if the healthcare team agreed on it. Further research is warranted to define conscientious objection and determine its possible effects, feasibility, and scope in Turkey.

The effects of nursing students' conscientious intelligence on their cultural sensitivity levels

PURPOSE

This study was carried out to determine the relationship between the level of conscientious intelligence and cultural sensitivity among nursing students.

METHODS

This is a cross-sectional descriptive design. The sample of this study consisted of 172 nursing students. The study data were collected using a sociodemographic data form, the intercultural sensitivity scale, and the conscientious intelligence scale.

RESULTS

The mean intercultural sensitivity scale score was 80.07 ± 10.68, and the mean conscientious intelligence scale score was 120.89 ± 12.32. Also, a positive relationship was determined between both scales that the nursing students obtained.

PRACTICE IMPLICATIONS

The scale scores of nursing students were found to be a moderate level. As students' conscientious intelligence levels increased, their intercultural sensitivity was determined to increase, as well.

Clarifying the concept of conscience in nurses' ethical performance in Iran: a concept analysis study

Although conscience, as an ethical concept, has emerged widely in the field of nursing, its functional meaning and its effects on nurses' performance are not clear. Therefore, the present study aimed to analyze the concept of conscience in the context of Iranian nurses’ ethical performance.

This study used a hybrid model including theoretical, fieldwork, and final analytic stages. In the theoretical phase, English and Persian articles published up to 2020 and indexed by scientific databases were analyzed. In the fieldwork phase, semi-structured in-depth interviews were conducted on nurse participants. The last two stages were jointly considered to draw the study’s conclusions.

In the theoretical phase, conscience was considered as a context-dependent concept, an inner voice, and a criterion for distinguishing right from wrong. The fieldwork phase’ results were categorized into three themes: “perception of conscience”, “commands of conscience”, and “obedience to conscience. The final definition was reached by merging the theoretical and field stages.

This article aimed at investigating the relevance of conscience to ethical practice in the nursing field. Findings show that conscience is an inner feeling or voice that plays a vital role in providing ethical care by nurses.

The extent and nature of stress of conscience among healthcare workers: A scoping review

BACKGROUND

Healthcare workers experience morally stressful situations during delivery of care which may trouble their conscience. Literature emerging in the context of global pandemics suggest increased frequency of morally stressful situations in healthcare and a link with negative outcomes such as attrition and burnout. Little is known about the emerging concept of stress of conscience which could provide a meaningful way to highlight and address these morally stressful situations in healthcare.

AIM

The aim of this scoping review was to provide an overview of the literature on, (i) the extent, (ii) the factors associated, and (iii) the interventions to prevent or mitigate stress of conscience among healthcare workers.

DESIGN

The study was guided by the framework provided by Arksey and O'Malley in 2005 and the PRISMA Guidelines. Relevant healthcare databases were searched in November 2020 to identify relevant studies.

RESULTS

The search identified 24 studies for inclusion in the analysis, 19 of these were from Nordic countries, particularly Sweden. Across those studies, stress of conscience was prevalent among healthcare workers and the levels varied with demographic factors, individual personalities, perceptions of belonging and the workplace culture and environment. Stress of conscience was associated with negative outcomes such as burnout, moral burden, workplace stress, and low quality of care. Although there were few quality interventions studies, facilitating healthcare workers to provide person-centred care appears to be a promising intervention.

CONCLUSIONS

The concept of stress of conscience provides a contemporary framework to assess, highlight and discuss the degree of the negative impact of perceived violations of professional and personal values in healthcare. However, the limited studies suggest that exploring stress of conscience, including trials of potential interventions, particularly beyond Nordic countries is essential to fill the gaps in the literature.

Conscience and conscientious objection in nursing: A personalist bioethics approach

The ability of nurses to act as moral agents in accordance with their conscience is both an essential human freedom and an important part of professional ethics. Recent developments in Canada related to Medical Assistance in Dying have revealed new and important challenges related to conscientious objection - challenges that may require rethinking of how nurses do professional ethics. Notably, the inclusion of a personalist bioethical approach is needed to introduce and explicate what conscience is for nurses to be able to apply it to nursing practice. In this article, we explore the importance of conscience and conscientious objection as ethical concepts to support nurses in addressing issues of conscience amid ethically challenging situations. We discuss how a personalist basis for conscience can support nurses to inclusively engage with one another across diverse moral perspectives.

Mental health nursing and conscientious objection to forced pharmaceutical intervention

This paper attempts a critical discussion of the possibilities for mental health nurses to claim a particular right of conscientious objection to their involvement in enforced pharmaceutical interventions. We nest this within a more general critique of perceived shortcomings of psychiatric services, and injustices therein. Our intention is to consider the philosophical and practical complexities of making demands for this conscientious objection before arriving at a speculative appraisal of the potential this may hold for broader aspirations for a transformed or alternative mental health care system, more grounded in consent than coercion. We consider a range of ethical and practical dimensions of how to realize this right to conscientious objection. We also rely upon an abolition democracy lens to move beyond individual ethical frameworks to consider a broader politics for framing these arguments.

Assessments of stress of conscience, burnout and social support amongst care providers in home care and residential care for older people

BACKGROUND

Studies points to that levels of stress of conscience and burnout among staff in healthcare contexts may seriously affect their health.

AIM

To compare assessments and associations of stress of conscience, perceptions of conscience, social support and burnout amongst care providers working in home care respectively residential care for older people.

METHODS

This cross-sectional descriptive comparative study was performed among all care providers working in home care (n = 227) and residential care of older people (n = 354) in a municipality in northern Sweden. Data was collected using four different questionnaires. Analysis were performed using partial least square regression, descriptive statistics, statistical tests and effect size measures.

RESULTS

Care providers in residential care of older people assessed higher levels of stress of conscience compared to those working in home care. Exhaustion was an important predictor for belonging to the group of care providers working in residential care of older people. The most important predictor for belonging to the group of care providers working in home care were social support from one's immediate superior and co-workers. Women assessed significantly higher levels of stress of conscience and exhaustion compared to men.

CONCLUSION

Further research seems needed to investigate what the high levels of stress of conscience is caused by. A combined intervention consisting of work-directed measures against burnout and measures aiming at reducing stress of conscience is suggested.

Stress of Conscience Questionnaire (SCQ): exploring dimensionality and psychometric properties at a tertiary hospital in Australia

BACKGROUND

This study explored the psychometric properties and dimensionality of the Stress of Conscience Questionnaire (SCQ) in a sample of health professionals from a tertiary-level Australian hospital. The SCQ, a measure of stress of conscience, is a recently developed nine-item instrument for assessing frequently encountered stressful situations in health care, and the degree to which they trouble the conscience of health professionals. This is relevant because stress of conscience has been associated with negative experiences such as job strain and/or burnout. The validity of SCQ has not been explored beyond Scandinavian contexts.

METHODS

A cross-sectional study of 253 health professionals was undertaken in 2015. The analysis involved estimates of reliability, variability and dimensionality. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were used to explore dimensionality and theoretical model fit respectively.

RESULTS

Cronbach's alpha of 0.84 showed internal consistency reliability. All individual items of the SCQ (N = 9) met the cut-off criteria for item-total correlations (> 0.3) indicating acceptable homogeneity. Adequate variability was confirmed for most of the items, with some items indicating floor or ceiling effects. EFA retained a single latent factor with adequate factor loadings for a unidimensional structure. When the two-factor model was compared to the one-factor model, the latter achieved better goodness of fit supporting a one-factor model for the SCQ.

CONCLUSION

The SCQ, as a unidimensional measure of stress of conscience, achieved adequate reliability and variability in this study. Due to unidimensionality of the tool, summation of a total score can be a meaningful way forward to summarise and communicate results from future studies, enabling international comparisons. However, further exploration of the questionnaire in other cultures and clinical settings is recommended to explore the stability of the latent one-factor structure.

Knowledge, Attitudes, and Interactions with Chaplains and Nursing Staff Outcomes: A Survey Study

We conducted a cross-sectional survey of nursing staff (n = 51) in an academic hospital finding a significant inverse relationship between the frequency of chaplaincy interaction and perceived stress (r = - 0.27, p = 0.05). We also found a significant positive relationship between rated importance of having a chaplain at the hospital and secondary trauma (r = 0.30, p = 0.03). There was a significant positive relationship between religiosity and rated importance for having a chaplain (r = 0.30, p = 0.03) and rated helpfulness of chaplains (r = 0.32, p = 0.02). Similarly, there was a significant positive relationship between spirituality and average length of conversations with a chaplain, rated importance for having a chaplain, and helpfulness of chaplains (r = 0.32, p = 0.03; r = 0.44, p = 0.001; and r = 0.52, p = 0.0001, respectively). Interaction with chaplains is associated with decreased employee perceived stress for nursing staff who provide care for severely ill patients.

Care providers' troubled conscience related to an implementation of a time management system in residential care for older people-a participatory action research study

BACKGROUND

Care providers in residential care for older people often refer to time shortage, a problem that may generate troubled conscience.

AIM

The aim of the study was to describe a PAR process to assist care providers in municipal residential care for older people to constructively deal with their troubled conscience related to an implemented time management system.

METHOD

This intervention study was carried out with 14 care providers and their manager in residential care for older people with the support of participatory action research (PAR). The recorded PAR sessions were transcribed and compiled with inspiration from content analysis.

ETHICAL CONSIDERATIONS

The participants were given oral and written information and gave their written informed consent.

FINDINGS

The PAR process was found to empower the participants to form their own structure of the practical professional planning, adapted to the residents needs and to their daily work. In this process, participants used their troubled conscience as a driving force and as an asset.

CONCLUSION

Instead of launching change without any deeper information, it is important to carefully prepare, involve and inform those who are going to execute the change. Meeting places should be arranged wherein care providers have the opportunity to share and reflect on challenging situations that can generate troubled conscience, especially when comprehensive changes in their work are going to be implemented.

Nursing and midwifery students' attitudes towards principles of medical ethics in Kermanshah, Iran

Background

Professional ethics is one of the important topics, which includes various rights such as respecting the patient’s right to choose (autonomy), being useful (beneficence), being harmless (non- maleficence), and respecting the justice, integrity, and confidentiality of information. Adherence to these principles can increase the quality of care and patient satisfaction. Since determining the current attitude of students towards ethics plays an important role in educational programs, this study was conducted to evaluate the attitude of nursing and midwifery students of Kermanshah University of Medical Sciences towards six principles of professional ethics.

Methods

In this cross-sectional study, 76 undergraduate nursing and midwifery students (who were at the final years of their study) were selected to participate in this study by census method. The data collection tool was a valid and reliable questionnaire on the principles of medical ethics. Data were analyzed using descriptive and inferential statistics.

Results

The study sample consisted of 49 (64.5%) nursing and 27 (35.5%) midwifery students with an average age of 23 ± 1.4 years. The mean score of nursing and midwifery students’ attitude towards medical ethics was 95.01 ± 4.8 in basis of 100, and was 94.56 ± 4.9 for nursing students and 96.04 ± 4.7 for midwifery students. Majority of the samples (96.26%) had positive attitude towards medical ethics and 3.73% had a relatively positive attitude. No statistically significant relationship was found between the attitude of students and variables of gender (t = − 0.27, p = 0.78), field of study (t = − 1.3, p = 0.99), marital status (t = − 1.378, p = 0.178), and age (F = 1.606, p = 0.2).

Conclusion

All students in this study had a positive attitude towards the principles of medical ethics, and this is a valuable asset for clinical environments. To increase the generalizability of the study, further studies with bigger sample size on the students of various disciplines of medical sciences is recommended.

Nurses' use of conscientious objection and the implications for conscience

AIMS

To explore the meaning of conscience for nurses in the context of conscientious objection (CO) in clinical practice.

DESIGN

Interpretive phenomenology was used to guide this study.

DATA SOURCES

Data were collected from 2016 - 2017 through one-on-one interviews from eight nurses in Ontario. Iterative analysis was conducted consistent with interpretive phenomenology and resulted in thematic findings.

REVIEW METHODS

Iterative, phased analysis using line-by-line and sentence highlighting identified key words and phrases. Cumulative summaries of narratives thematic analysis revealed how nurses made meaning of conscience in the context of making a CO.

RESULTS

Conscience issues and CO are current, critical issues for nurses. For Canadian nurses this need has been recently heightened by the national legalization of euthanasia, known as Medical Assistance in Dying in Canada. Ethics education, awareness, and respect for nurses' conscience are needed in Canada and across the profession to support nurses to address their issues of conscience in professional practice.

CONCLUSION

Ethical meaning emerges for nurses in their lived experiences of encountering serious ethical issues that they need to professionally address, by way of conscience-based COs.

IMPACT

This is the first study to explore what conscience means to nurses, as shared by nurses themselves and in the context of CO. Nurse participants expressed that support from leadership, regulatory bodies, and policy for nurses' conscience rights are indicated to address nurses' conscience issues in practice settings.

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.

Factors affecting emergency medical dispatchers' decision-making: a qualitative study

Introduction

Prehospital emergency medical service dispatchers should make prompt and appropriate decisions to save the life of victims. The complexity of timely and reasonable decision-making in life-threatening conditions has driven researchers to investigate varying aspects of the emergency medical dispatch (EMD) process. The purpose of this study was to explore the contributors to appropriate and prompt decision-making among dispatchers.

Methods

A qualitative study through thematic analysis was designed. Data were collected using observation and semistructured interviews with 16 authorities and dispatchers in seven EMDs across Iran.

Results

The study found “responsiveness” as the main category contributing to improved decision-making in EMD. The components introduced in this study for dispatchers’ responsiveness consisted of two categories. The first was “personal values” including faith and belief, eagerness to help, service excellence, altruism, respect, and impartiality in clinical judgment. The second was “professional attitudes” resulting from education and experience, including the recognition of emergency as a threat to health, sensitivity in triage, response to all requests for help, care for early warnings, commitment to organizational goals and standards, attention to the emergency medical service social support responsibility, and professional temperance.

Conclusion

In this study, responsiveness was identified as a main category in improving the decision-making process among dispatchers. To attain responsiveness, institutionalization of its values and establishment of EMD-specific professional attitudes in dispatchers should be taken into consideration.

Conscientious objection and nurses: Results of an interpretive phenomenological study

Background:

While conscientious objection is a well-known phenomenon in normative and bioethical literature, there is a lack of evidence to support an understanding of what it is like for nurses to make a conscientious objection in clinical practice including the meaning this holds for them and the nursing profession.

Research question:

The question guiding this research was: what is the lived experience of conscientious objection for Registered Nurses in Ontario?

Research design:

Interpretive phenomenological methodology was used to gain an in-depth understanding of what it means to be a nurse making a conscientious objection. Purposive sampling with in-depth interview methods was used to collect and then analyze data through an iterative process.

Participants and research context:

Eight nurse participants were interviewed from across practice settings in Ontario, Canada. Each participant was interviewed twice over 9 months.

Ethical considerations:

This study was conducted in accordance with Health Science Research Ethics Board approval and all participants gave consent.

Findings:

Six themes emerged from data analysis: encountering the problem, knowing oneself, taking a stand, alone and uncertain, caring for others, and perceptions of support.

Discussion:

This study offers an initial understanding of what it is like to be a nurse making a conscientious objection in clinical practice. Implications for nursing practice, education, policy, and further research are discussed.

Conclusion:

Addressing ethical issues in nursing practice is complex. The need for education across nursing, healthcare disciplines and socio-political sectors is essential to respond to nurses’ ethical concerns giving rise to objections. Conscience emerged as an informant to nurses’ conscientious objections. The need for morally inclusive environments and addressing challenging ethical questions as well as the concept of conscience are relevant to advancing nursing ethics and ethical nursing practice.

Predict Moral Distress Using Workplace Stress, Stress of Conscience Mediated by Coping Using Roy Adaptation Model: A Path Analysis

BACKGROUND

Moral distress can be predisposed when nurses are exposed to ambiguous moral situations.

PURPOSE

Is to test a conceptual model based on Roy adaptation model (RAM) to examine the relationship among workplace stress, conscience stress, and moral distress mediated by coping.

DESIGN

A correlational, cross sectional.

RESULTS

Data were collected from 199 licensed nurses. The findings indicated that workplace stress was related negatively to coping processes (β = -.12) and that stress of conscience was predictive of greater use of coping process (β = -.21).

CONCLUSION

The results indicated that the model suggested based on RAM is saturated and is the perfect fit. However, the alternative models indicated that workplace stress moderately predicted moral distress.

Conscience, conscientious objection, and nursing: A concept analysis

BACKGROUND:

Ethical nursing practice is increasingly challenging, and strategies for addressing ethical dilemmas are needed to support nurses' ethical care provision. Conscientious objection is one such strategy for addressing nurses' personal, ethical conflicts, at times associated with conscience. Exploring both conscience and conscientious objection provides understanding regarding their implications for ethical nursing practice, research, and education.

RESEARCH AIM:

To analyze the concepts of conscience and conscientious objection in the context of nurses.

DESIGN:

Concept analysis using the method by Walker and Avant.

RESEARCH CONTEXT:

Data were retrieved from Philosopher's Index, PubMed, and CINAHL with no date restrictions.

ETHICAL CONSIDERATION:

This analysis was carried out per established, scientific guidelines.

FINDINGS:

Ethical concepts are integral to nursing ethics, yet little is known about conscientious objection in relation to conscience for nurses. Of note, both concepts are well established in ethics literature, addressed in various nursing codes of ethics and regulatory bodies, but the meaning they hold for nurses and the impact they have on nursing education and practice remain unclear.

DISCUSSION AND CONCLUSION:

This article discusses the relevance of conscience and conscientious objection to ethical nursing practice and proposes a model case to show how they can be appreciated in the context of nurses. Conscientious objection is an option for ethical transparency for nurses but is situated in contentious discussions over its use and has yet to be fully understood for nursing practice. Conscience is an element in need of more exploration in the context of conscientious objection. Further research is warranted to understand how nurses respond to conscience concerns in morally, pluralistic nursing contexts.

Conflicts of conscience in the neonatal intensive care unit: Perspectives of Alberta

Background:

Limited knowledge of the experiences of conflicts of conscience found in nursing literature.

Objectives:

To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta.

Research design:

Interpretive description was selected to help situate the findings in a meaningful clinical context.

Participants and research context:

Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta.

Ethical consideration:

Ethics approval from the Health Research Ethics Board at the University of Alberta.

Findings:

Three common themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses.

Discussion and conclusion:

The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection.

Experiences of a PAR Intervention in Care for Older People

Participatory action research (PAR) is an approach for dealing with problematic areas in practice. Follow-up studies in which participants describe their participation in PAR in detail are rare. This follow-up study aimed to describe care providers' (CPs) experiences of having participated in a PAR intervention designed to assist them to constructively deal with troubled conscience. Twenty-nine CPs who participated in a PAR intervention were interviewed 2 to 4 months post-intervention. Content analysis was used to analyze the data. The analysis revealed three main categories: the importance of having a communal and collaborative meeting place, perceived changes in daily life, and "It has been good, but it has not solved all of our problems." Using PAR to deal with troubled conscience might be an important organizational investment for the future that can help prevent ill health among CPs and maintain or improve the quality of care.

Assessments of Stress of Conscience, Perceptions of Conscience, Burnout, and Social Support Before and After Implementation of a Participatory Action-Research-Based Intervention

Interventions aiming to constructively address stress of conscience are rare. The aim of the study was to compare assessments of stress of conscience, perceptions of conscience, burnout, and social support among health care personnel (HCP) working in municipal residential care of older adults, before and after participation in a participatory action research (PAR) intervention aiming to learn to constructively deal with troubled conscience. Questionnaire data were collected at baseline and at follow-up (1-year interval; n = 29). Descriptive statistics and nonparametric statistical tests were used to make comparisons between baseline and follow-up. HCP gave significantly higher scores to the question, “Are your work achievements appreciated by your immediate superior?” at follow-up compared with baseline. No significant differences in levels of stress of conscience and burnout at follow-up were found. The results suggested that a PAR intervention aiming to learn HCP to deal with their troubled conscience in difficult situations could be partially successful.

A grounded theory of humanistic nursing in acute care work environments

Background:

Humanistic nursing practice which is dominated by technological advancement, outcome measurement, reduced resources, and staff shortages is challenging in the present work environment.

Objective:

To examine the main concern in humanistic nursing area and how the way it is solved and resolved by Iranian nurses in acute care setting.

Research design:

Data were collected from interviews and observations in 2009–2011 and analyzed using classic grounded theory. Memos were written during the analysis, and they were sorted once theoretical saturation occurred.

Participants and research context:

In total, 22 nurses, 18 patients, and 12 families from two teaching hospitals in Tehran were selected by purposeful and theoretical sampling.

Ethical considerations:

The research was approved by the Ethics Committee of the university and hospitals.

Results:

The main concern for the nurses is the violation of their rights. They overcome this concern when there is a synergy of situation–education/learning, that is, a positive interaction between education and learning of values and sensitivity of the situation or existence of care promotion elements. They turn to professional values and seeking and meeting others’ needs, resulting in “success and accomplishment” of nurse/nursing manager and patient/family.

Conclusion:

This theory shows that professional values, elements of care promotion, and sensitivity of the situation have a key role in activation of humanistic approach in nursing. Violation of the nurses’ professional rights often leads to a decrease in care, but these factors make the nurses practice in an unsparing response approach. It is necessary to focus on development of professional values and provide essential elements of care promotion as changeable factors for realization of humanistic nursing although there is a context in which the nurses’ rights are violated.

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.

Levels of Conscience and Related Factors among Iranian Oncology Nurses

BACKGROUND

Having a conscience is one of the main pre-requisite of providing nursing care. The knowledge regarding levels of conscience among nurses in eastern countries is limited. So, the purpose of this study was to examine the level of conscience and its related factors among Iranian oncology nurses.

MATERIALS AND METHODS

This descriptive-correlational study was conducted in 3 hospitals in Tabriz, Iran. Overall, 68 nurses were selected using a non-probability sampling method. The perceptions of conscience questionnaire was used to identify the levels of conscience among nurses. The data were analyzed using SPSS version 13.0.

RESULTS

The mean nurses' level of conscience scores was 72.7. In the authority and asset sub-scales nurses acquired higher scores. The mean of nurses' scores in burden and depending on culture sub-scales were the least. Also, there were no statistical relationship between some demographic characteristics of participants and their total score on the perceptions of conscience questionnaire.

CONCLUSIONS

According to study findings Iranian nurses had high levels of conscience. However, understanding all the factors that affect nurses' perception of conscience requires further studies.

Clear conscience grounded in relations: Expressions of Persian-speaking nurses in Sweden

Background:

Conscience is an important concept in ethics, having various meanings in different cultures. Because a growing number of healthcare professionals are of immigrant background, particularly within the care of older people, demanding multiple ethical positions, it is important to explore the meaning of conscience among care providers within different cultural contexts.

Research objective:

The study aimed to illuminate the meaning of conscience by enrolled nurses with an Iranian background working in residential care for Persian-speaking people with dementia.

Research design:

A phenomenological hermeneutical method guided the study.

Participants and research context:

A total of 10 enrolled nurses with Iranian background, aged 33–46 years, participated in the study. All worked full time in residential care settings for Persian-speaking people with dementia in a large city, in Sweden.

Ethical considerations:

The study was approved by the Regional Ethical Review Board for ethical vetting of research involving humans. Participants were given verbal and written study information and assured that their participation was voluntary and confidential.

Findings:

Three themes were constructed including perception of conscience, clear conscience grounded in relations and striving to keep a clear conscience. The conscience was perceived as an inner guide grounded in feelings, which is dynamic and subject to changes throughout life. Having a clear conscience meant being able to form a bond with others, to respect them and to get their confirmation that one does well. To have a clear conscience demanded listening to the voice of the conscience. The enrolled nurses strived to keep their conscience clear by being generous in helping others, accomplishing daily tasks well and behaving nicely in the hope of being treated the same way one day.

Conclusion:

Cultural frameworks and the context of practice needed to be considered in interpreting the meaning of conscience and clear conscience.

The Evolution of Professional Nursing Culture in Italy: Metaphors and Paradoxes

We explored the perceptions of Italian nurses regarding their developing culture as a health profession. We sought to understand the ongoing evolution of the nursing profession and the changes that were central to it becoming an intellectual discipline on par with the other health professions in Italy. In 2010, the Regulatory Board of Nursing established a center of excellence to build evidence-based practice, advocate for interdisciplinary health care, and champion health profession reforms for nursing. In this study, focus groups—involving 66 nurse participants from various educational, clinical, and administrative backgrounds—were utilized to better ascertain how the profession has changed. Six themes, three of them metaphors—“vortex,” “leopard spots,” and “deductive jungle”—explain nurses’ experiences of professional change in Italy between 2001 and 2011 and the multiple dimensions that characterize their professional identity and autonomy.

Dealing with troubled conscience in municipal care of older people

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.

Ethical diversity and the role of conscience in clinical medicine

In a climate of plurality about the concept of what is "good," one of the most daunting challenges facing contemporary medicine is the provision of medical care within the mosaic of ethical diversity. Juxtaposed with escalating scientific knowledge and clinical prowess has been the concomitant erosion of unity of thought in medical ethics. With innumerable technologies now available in the armamentarium of healthcare, combined with escalating realities of financial constraints, cultural differences, moral divergence, and ideological divides among stakeholders, medical professionals and their patients are increasingly faced with ethical quandaries when making medical decisions. Amidst the plurality of values, ethical collision arises when the values of individual health professionals are dissonant with the expressed requests of patients, the common practice amongst colleagues, or the directives from regulatory and political authorities. In addition, concern is increasing among some medical practitioners due to mounting attempts by certain groups to curtail freedom of independent conscience-by preventing medical professionals from doing what to them is apparently good, or by compelling practitioners to do what they, in conscience, deem to be evil. This paper and the case study presented will explore issues related to freedom of conscience and consider practical approaches to ethical collision in clinical medicine.

Healthcare personnel's experiences of situations in municipal elderly care that generate troubled conscience

Healthcare personnel may perceive troubled conscience when feeling inadequate and powerless. It is important to further explore healthcare personnel's descriptions of situations in daily work, which generate troubled conscience to increase the awareness of such situations. This study aimed to describe health care personnel's experiences of situations in municipal elderly care that generate troubled conscience. In this qualitative study, interviews were conducted with Registered and Enrolled nurses and nursing assistants (n = 20) working in municipal elderly care. The interviews were tape-recorded, transcribed verbatim and analysed with content analysis. Situations that generated troubled conscience was (i) Being caught between different demands, comprising being forced to prioritize between different residents' needs, being torn between residents'-/relatives'-/and co-workers' needs and expectations' and between work and private life, (ii) Being torn away from residents to other 'must do's', comprising stealing time from residents' to do housekeeping chore' and to 'obey' rules and recommendations, (iii) Feeling unable to relieve suffering, comprising falling short when striving to help, lacking knowledge, advice and support and time to ease residents' suffering and finally, (iv) Being part of providing care that is or feels wrong, comprising providing poor care and/or witnessing co-workers providing poor care, and being forced to give care that feels wrong. These findings identify important factors that generate stress of conscience (stress caused by troubled conscience), including difficulties with balancing priorities and following rules and recommendations that seem contrary to best care, and the need for interdisciplinary teamwork. Findings point to that sharing what conscience tells in the work team opens up possibilities for healthcare personnel to constructively deal with troubled conscience. Intervention studies are needed to explore whether such measures contribute to relieve the burden of troubled conscience and increase possibilities to provide high quality care.

Of courage and leaving safe harbors

If the health care system in the United States is to be sustainable, dramatic changes that result in better outcomes, lower costs, and improved quality are needed. As the largest group of health care providers, successful change will depend, in part, upon nursing practitioners, leaders, visionaries, advocates, and educators who are courageous enough to make difficult decisions and to follow through with actions. This philosophical inquiry addresses the nature of courage, types and motivations for courageous actions, and the complex psychological manifestations of thinking courageously. The inquiry concludes with educational and practical goals to promote proper use of courage in clinical practice.

An overview of ethics in maternal-child nursing

Ethical issues across the childbearing year are multiple and complex. This article addresses ethical challenges facing maternal-child nurses and identifies strategies for making ethical decisions utilizing ethical principles and frameworks. Coping strategies for dealing with moral distress, how nurses demonstrate moral courage, and the attributes of an effective ethical decision maker are described. Ethical issues related to healthcare team relationships are discussed, with implications for nurses provided.

Ethical practice in end-of-life care in Japan

Nurses are obliged to provide quality nursing care that meets the ethical standards of their profession. However, clear descriptions of ethical practice are largely missing in the literature. Qualitative research using a phenomenological approach was conducted to explicate ethical nursing practice in Japanese end-of-life care settings and to discover how ethical practices unfold in clinical situations. Two paradigm cases and contrasting narratives of memorable end-of-life care from 32 Japanese nurses were used to reveal four levels of ethical practice: ethical, distressed, uncertain, and unethical. Having the ability to actualize, justify, and recognize what is the good and/or right differentiated between these levels of ethical practice, empirical descriptions of which are given, followed by discussion of how nurses gain the skilled knowledge necessary for ethical practice.

Perceptions of conscience, stress of conscience and burnout among nursing staff in residential elder care

AIM

This paper is a report of a study of patterns of perceptions of conscience, stress of conscience and burnout in relation to occupational belonging among Registered Nurses and nursing assistants in municipal residential care of older people.

BACKGROUND

Stress and burnout among healthcare personnel and experiences of ethical difficulties are associated with troubled conscience. In elder care the experience of a troubled conscience seems to be connected to occupational role, but little is known about how Registered Nurses and nursing assistants perceive their conscience, stress of conscience and burnout.

METHOD

Results of previous analyses of data collected in 2003, where 50 Registered Nurses and 96 nursing assistants completed the Perceptions of Conscience Questionnaire, Stress of Conscience Questionnaire and Maslach Burnout Inventory, led to a request for further analysis. In this study Partial Least Square Regression was used to detect statistical predictive patterns.

RESULT

Perceptions of conscience and stress of conscience explained 41.9% of the variance in occupational belonging. A statistical predictive pattern for Registered Nurses was stress of conscience in relation to falling short of expectations and demands and to perception of conscience as demanding sensitivity. A statistical predictive pattern for nursing assistants was perceptions that conscience is an authority and an asset in their work. Burnout did not contribute to the explained variance in occupational belonging.

CONCLUSION

Both occupational groups viewed conscience as an asset and not a burden. Registered Nurses seemed to exhibit sensitivity to expectations and demands and nursing assistants used their conscience as a source of guidance in their work. Structured group supervision with personnel from different occupations is needed so that staff can gain better understanding about their own occupational situation as well as the situation of other occupational groups.

Utilitarian and common-sense morality discussions in intercultural nursing practice

Two areas of ethical conflict in intercultural nursing — who needs single rooms more, and how far should nurses go to comply with ethnic minority patients’ wishes? — are discussed from a utilitarian and common-sense morality point of view. These theories may mirror nurses’ way of thinking better than principled ethics, and both philosophies play a significant role in shaping nurses’ decision making. Questions concerning room allocation, noisy behaviour, and demands that nurses are unprepared or unequipped for may be hard to cope with owing to physical restrictions and other patients’ needs. Unsolvable problems may cause stress and a bad conscience as no solution is ‘right’ for all the patients concerned. Nurses experience a moral state of disequilibrium, which occurs when they feel responsible for the outcomes of their actions in situations that have no clear-cut solution.