Legal Regulations and the Anticipation of Moral Distress of Prospective Nurses: A Comparison of Selected Undergraduate Nursing Education Programmes

Moral distress is commonly experienced by nurses in all settings. This bears the risk of a reduced quality of care, burnout and withdrawal from the profession. One approach to the prevention and management of moral distress is ethical competence development in undergraduate nursing education. Profession-specific legal regulations function as a foundation for the decision on the educational content within these programmes. This theoretical article presents the extent to which legal regulations may open framework conditions that allow for the comprehensive preparation of prospective nurses to manage moral distress. The legal frameworks and the immediate responsibilities regarding their realisation in the context of undergraduate nursing education vary slightly for the three chosen examples of Switzerland, Austria and Germany. While an increased awareness of ethics’ education is represented within the nursing laws, no definite presumption can be made regarding whether undergraduate nursing students will be taught the ethical competencies required to manage moral distress. It remains up to the curriculum design, the schools of nursing and instructors to create an environment that allows for the realisation of corresponding learning content. For the future, the establishment of professional nursing associations may help to emphasise acutely relevant topics, including moral distress, in undergraduate nursing education.

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.

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.

The ethical dilemma of placebo use in clinical practice

The clinical use of placebo that involves some ethical issues has led to much controversy. From the standpoint of both supporters and opponents, this article discusses this topic from three ethical principles such as beneficence, justice, and autonomy and also gives the recommendations. Finally, the moral dilemma caused by the different views between nurses and doctors in clinical practice is discussed.

Strengthening Perceptions of Ethical Competence Among Nursing Students and Graduates

INTRODUCTION

Ethical competence is part of all health-care professionals' general competence. It relates to moral issues and is based on the professionals' knowledge, skills, and attitudes for coping with ethical dilemmas. Ethics education aims to increase nursing students' and nursing graduates' ethical self-confidence. Previous research has found many gaps in ethical education content and poor understanding of how these gaps affect graduates.

OBJECTIVES

This study aims to evaluate an advanced education workshop held in the nursing department in Max Stern Yezreel Valley College aimed at strengthening the self-perceptions of ethical competence, to address the above gap, by raising students' self-efficacy when coping with ethical dilemmas.

METHODS

The effectiveness of the workshop for nursing students was evaluated using the Generalized Self-Efficacy Scale and at three points in time: before the workshop, after the workshop, and after graduation.

RESULTS

Statistically significant differences were found in overall self-efficacy: before the workshop (mean of 2.42), after the workshop (mean of 2.13), and for graduates (mean of 1.58) with p < .000 on a scale ranging from 1 to 5 (1 indicating high self-efficacy). Mean scores for students' evaluation after the workshop and for graduates were 7.8 and 7.25, respectively, on a scale ranging from 1 to 10, where 10 indicates high self-efficacy. Graduates presented a high mean score regarding their ability to cope with ethical dilemmas when compared with other nurses working with them (mean of 7.4, on a scale ranging from 1 to 10).

CONCLUSION

Levels of self-efficacy with regard to coping with ethical dilemmas increased over time, suggesting that the workshop strengthened the self-perception of ethical competence for nursing students and graduates.

Moral resilience through harmonised connectedness in intensive care nursing: A grounded theory study

OBJECTIVES

To examine intensive care nurses' main concerns in respect of ethical practice, and to investigate how nurses continue to practise in an ethical way despite challenges in order to offer a conceptualisation of moral resilience.

RESEARCH METHODOLOGY/DESIGN

This qualitative study followed Glaser and Strauss' version of grounded theory. The study was reviewed, and approved, by research ethics committees in Switzerland and in England.

MAIN OUTCOME MEASURES

Data consisted of field notes and in-depth interviews with 16 nurses working in intensive care in Switzerland and memos developed during the analysis. Data analysis followed the constant comparative method. This study took place between 2014 and 2017.

FINDINGS

This study identified new understanding in how intensive care nurses manage their concerns and challenges regarding moral practice. The main category for moral resilience is harmonising connectedness, which represents intensive care nurses' main concern with regard to their moral life, and at the same time, represents the pattern of behaviour in their social interactions and what they yearn for.

CONCLUSIONS

This study offers new insight into intensive care nurses' moral practice, moral resilience and strategies nurses use to achieve moral wellbeing.

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.

Exploring the Perceptions of Core Values of Nursing in Taiwanese Nursing Students at the Baccalaureate Level

BACKGROUND

The core values of nursing are a standard component of the nursing curriculum in Taiwan. Therefore, these values provide an essential guide for educating and evaluating the learning outcomes of nursing students. Student perceptions of those core values that relate to the process of curricula learning are key to measuring the core values of nursing.

PURPOSE

This study explores the views on the core values of nursing of baccalaureate-level nursing students at a Taiwanese university.

METHODS

This qualitative study collected data from the reflection reports of 109 students and analyzed these data using thematic content analysis.

RESULTS

The results of this study identified that the learning of core values of nursing tends to utilize the latent curriculum rather than the open curriculum. Critical thinking was perceived and experienced by asking "why." General clinical skills and basic biomedical science were categorized collectively as care ability, which relates to the thinking, analysis, and mapping of client health problems. The value of communication and teamwork capability was defined as the sequential process of accepting, interacting, communicating, and collaborating. Caring was defined as contributing empathy with respect to one's self and to others. Ethics was defined as a moral perspective, as respecting others, and as prioritizing the needs of clients. Accountability was defined as a way of observing standards within the role given in a position. Finally, lifelong learning is a process of learning that encourages more aggressive learning.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

The progress of core values of nursing in this study reflects positive movement and achievement. The participants expressed the perception that the core values of nursing enhance understanding, which enables nursing educators to reframe the nursing curriculum to meet their learning needs. The perceptions of nursing students of core values of nursing may be used as a guide to increase clinical nursing competence in healthcare.

Duty and dilemma: Perioperative nurses hiding an objection to participate in organ procurement surgery

Perioperative nurses assist in organ procurement surgery; however, there is a dearth of information of how they encounter making conscientious objection requests or refusals to participate in organ procurement surgery. Organ procurement surgical procedures can present to the operating room ad hoc and can catch a nurse who may not desire to participate by surprise with little opportunity to refuse as a result of staffing, skill mix or organizational work demands. This paper that stems from a larger doctoral research study exploring the experiences of perioperative nurses participating in multi-organ procurement surgery used a grounded theory method to develop a substantive theory of the nurses' experiences. This current paper aimed to highlight the experiences of perioperative nurses when confronted with expressing a conscientious objection towards their participation in these procedures. A number of organizational and cultural barriers within the healthcare organization were seen to hamper their ability in expressing a conscience-based refusal, which lead to their reluctant participation. Perioperative nurses must feel safe to express a conscientious objection towards these types of surgical procedures and feel supported in doing so by their respective hospital organizations and not be forced to participate unwillingly.

Development and validation of a questionnaire to measure moral distress in community pharmacists

Background Pharmacists work within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment creates the potential for moral distress to occur due to the limitations it places on acting in congruence with moral judgements. Very little research regarding this phenomenon has been undertaken in pharmacy: thus, prominent research gaps have arisen for the development of a robust tool to measure and quantify moral distress experienced in the profession. Objective The aim of this study was to develop an instrument to measure moral distress in community pharmacists. Setting Community pharmacies in the United Kingdom. Method This study adopted a three-phase exploratory sequential mixed-method design. Three semi-structured focus groups were then conducted to allow pharmacists to identify and explore scenarios that cause moral distress. Each of the identified scenarios were developed into a statement, which was paired with twin seven-point Likert scales to measure the frequency and intensity of the distress, respectively. Content validity, reliability, and construct validity were all tested, and the questionnaire was refined. Main outcome measure The successful development of the valid instrument for use in the United Kingdom. Results This research has led to the development of a valid and reliable instrument to measure moral distress in community pharmacists in the UK. The questionnaire has already been distributed to a large sample of community pharmacists. Conclusion Results from this distribution will be used to inform the formulation of coping strategies for dealing with moral distress.

Conscientious Objection: Understanding the Right of Conscience in Health and Healthcare Practice

In situations of moral gravitas, healthcare professionals are largely protected in the Western world to invoke their right to conscientiously object to providing care that conflicts with their personal, moral, and religious beliefs. However, making a conscientious objection needs to be predicated by an understanding of conscience, and knowledge of conscience is largely absent in definition as well as discourse surrounding conscientious objection in healthcare practice. Moreover, current definitions of health do not place emphasis on the ethical well-being of patients as well as care providers. Exploring health as an ethical condition of wellness in the light of conscientious healthcare provision will be addressed in my paper. I will also discuss how a distance from conscience in conscientious objection could compromise a healthcare professional's right to conscientious objection, if the fundamental, human right to conscience is not protected in the first place, supported by a focus on the importance of health as a state of ethical well-being.

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.

[Ethical problems experienced by nurses in primary health care: integrative literature review]

The aim of this study is to identify ethical problems experienced by nurses in primary health care and resources for coping based on publications on the subject. An integrative literature review was performed between the months of October and November 2013, using the databases: BDTD, CINAHL, LILACS, MEDLINE, Biblioteca Cochrane, PubMed, RCAAP and SciELO. Articles, dissertations and theses published in Portuguese, English and Spanish were included, totalling 31 studies published from 1992 to 2013. This analysis resulted in four categories: ethical problems in the relationship between team members, ethical problems in the relationship with the user, ethical problems in health services management and resources for coping with ethical problems. Results showed that nurses need to be prepared to face ethical problems, emphasizing the importance of ethics education during the education process before and during professional practice to enhance the development of ethical sensitivity and competence for problem resolution.

Ethical competence as a coping resource for moral distress in nursing

The study's objectives were: to seek evidence on ethical situations experienced by nurses in the health services; to identify the coping resources which they use; and to ascertain the role of ethical competence in coping with moral distress. The integrative literature review was used as the method. The search was made in the LILACS, IBECS, MEDLINE, SciELO, CINAHL, PubMed, RCAAP and BDTD databases. A total of 23 studies was selected, based on previously established inclusion and exclusion criteria. The results indicate ethical questions experienced by the nurses in their relations with patients and family members, the team and the health system. Coping resources used by the professionals and implemented by the researchers are described. It may be concluded that the ethical challenges and moral distress are present in the nurses' work context, and the strategies aimed at promoting ethical competence, have positive consequences in coping with, and in reducing, levels of moral distress.

Psychiatric nursing: an unpopular choice

Research studies in the United States, the United Kingdom, New Zealand and Australia suggest that students do not consider psychiatric nursing as a popular career option. According to this research, there is a widespread concern about the nursing shortages in psychiatry. The demand for mental health services continues to grow and there is a need for strategies to recruit nurses for this specialized field. The purpose of this study was to identify the factors preventing undergraduate nursing students in South Africa (SA) from choosing psychiatric nursing as a career. A qualitative research design that aimed to explore and describe was used. Data were collected through the Nominal Group Technique. A sample of convenience of 27 final year nursing students from the School of Nursing at the University of the Free State as well as the Free State School of Nursing, situated in Bloemfontein (SA), voluntarily participated in this research. The following categories emerged from the content analysis of the data: personal factors, working environment, unprofessional behaviour, learning environment and the unclassified category. Psychiatric nursing as a career choice is in a predicament and nursing schools need to implement practical strategies to recruit future nurses for this field.

The issue of moral distress in community pharmacy practice: background and research agenda

OBJECTIVES

Moral distress arises from situations in which the individual identifies the morally right action required, but feels unable to act accordingly due to organisational constraints within the work place. Research into this phenomenon has focused predominately on the experience of those in the nursing profession, due to its perceived moral grounding and its traditionally subordinate role. As the conceptual boundaries of moral distress have developed, so too has the research interest in the experiences of other professional groups. Here, we seek to determine if there is scope to study moral distress in pharmacists.

METHODS

A review of the literature on moral distress in healthcare professions was undertaken.

KEY FINDINGS

Pharmacists working in the UK operate within a highly-regulated occupational sphere, and are bound by strict legal frameworks and codes of professional conduct. This regulatory environment, when combined with the emerging recognition that pharmacy is a value-based profession with a strong ethical grounding, creates the potential for moral distress to occur due to the limitations placed on acting in congruence with ethical judgements. Studies concerning moral distress in nurses have identified significant negative consequences for both the practitioner and for the quality of patient care.

CONCLUSIONS

To date, the incidence of moral distress among UK-based community pharmacists remains unexamined. Research must be undertaken to determine what situations cause the highest instances of moral distress for community pharmacists, and the extent to which these pharmacists experience moral distress in their working lives.

Researching moral distress among New Zealand nurses: a national survey

BACKGROUND

Moral distress has been described as a major problem for the nursing profession, and in recent years, a considerable amount of research has been undertaken to examine its causes and effects. However, few research projects have been performed that examined the moral distress of an entire nation's nurses, as this particular study does.

AIM/OBJECTIVE

The purpose of this study was to determine the frequency and intensity of moral distress experienced by registered nurses in New Zealand.

RESEARCH DESIGN

The research involved the use of a mainly quantitative approach supported by a slightly modified version of a survey based on the Moral Distress Scale-Revised.

PARTICIPANTS AND RESEARCH CONTEXT

In total, 1500 questionnaires were sent out at random to nurses working in general areas around New Zealand and 412 were returned, giving an adequate response rate of 27%.

ETHICAL CONSIDERATIONS

The project was evaluated and judged to be low risk and recorded as such on 22 February 2011 via the auspices of the Massey University Human Ethics Committee.

FINDINGS

Results indicate that the most frequent situations to cause nursing distress were (a) having to provide less than optimal care due to management decisions, (b) seeing patient care suffer due to lack of provider continuity and (c) working with others who are less than competent. The most distressing experiences resulted from (a) working with others who are unsafe or incompetent, (b) witnessing diminished care due to poor communication and (c) watching patients suffer due to a lack of provider continuity. Of the respondents, 48% reported having considered leaving their position due to the moral distress.

CONCLUSION

The results imply that moral distress in nursing remains a highly significant and pertinent issue that requires greater consideration by health service managers, policymakers and nurse educators.

Patient experience in the emergency department: inconsistencies in the ethic and duty of care

AIMS AND OBJECTIVES

To understand how people who present on multiple occasions to the emergency department experience their health professionals' moral comportment (ethic of care and duty of care); and to understand the consequences of this for 'people who present on multiple occasions' ongoing choices in care.

BACKGROUND

People (n = 34) with chronic illness who had multiple presentations were interviewed about the role that emergency departments played within their lives and health-illness journey. Unprompted, all participants shared views about the appropriateness or inappropriateness of the care they received from the health professionals in the emergency departments they had attended. These responses raised the imperative for specific analysis of the data regarding the need for and experience of an ethic of care.

DESIGN

Qualitative description of interview data (stage 3 of a multimethod study).

METHODS

The methods included further analysis of existing interviews, exploration of relevant literature, use of Tronto's ethic of care as a theoretical framework for analysis, thematic analysis of people who present on multiple occasions' texts and explication of health professionals' moral positions in relation to present on multiple occasions' experiences.

RESULTS

Four moral comportment positions attributed by the people who present on multiple occasions to the health professionals in emergency department were identified: 'sustained and enmeshed ethic and duty of care', 'consistent duty of care', 'interrupted or mixed duty and ethic of care', and 'care in breach of both the ethic and duty of care'.

CONCLUSIONS

People who present on multiple occasions are an important group of consumers who attend the emergency department. Tronto's phases/moral elements in an ethic of care are useful as a framework for coding qualitative texts. Investigation into the bases, outcomes and contextual circumstances that stimulate the different modes of moral comportment is needed.

RELEVANCE TO CLINICAL PRACTICE

Findings carry implications for emergency department care of people who present on multiple occasions and for emergency department health professionals to increase awareness of their moral comportment in care.

Contribution of ethics education to the ethical competence of nursing students

Aims:

To review the literature on perceptions of nursing students and/or educators on the contribution of ethics education to ethical competence in nursing students.

Background:

Nurses do not always demonstrate the competencies necessary to engage in ethical practice. Educators continue to debate about the best ways to teach ethics to nurses so that they can develop ethical competencies.

Data sources:

MEDLINE, Embase, CINAHL, PsycINFO, and Web of Science.

Review methods:

A total of 15 articles with a quantitative, qualitative, or mixed-methods design published between January 1992 and March 2012 were analyzed.

Results:

According to students and educators, ethics education increases ethical perception of nursing students and the development of reflective and analytical skills. However, its contribution to the development of ethical behavior was barely mentioned. The accounts of students and educators revealed essential features of effective ethics education: active involvement of students in case study discussions and use of ethical frameworks. The use of activating educational strategies requires a safe learning environment where students can openly reflect on values at stake in their care practice.

Conclusion:

A better understanding of how students learn to develop ethical skills and of influencing factors can guide educators to develop ethics courses for nursing curriculum. Future research needs to focus on the methodological accuracy of sampling and measuring instruments.

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.

Reasons Registered Nurses Report Serious Wrongdoings in a Public Teaching Hospital

This study examined reasons a registered nurse would report a wrongdoing within a public teaching hospital. Of a group of 238 initial respondents, 30% reported they had observed a wrongdoing in the past year, with 68 nurses indicating they had reported a wrongdoing in the past year. The latter group was the focus of this study. They indicated through a self-report survey that incidents threatening the well-being of patients and their professional ethics were more likely to be reported within their organizations. Observer anonymity was perceived to have a small, but important effect on nurses reporting a wrongdoing in this sample. A manipulation check of the initial 238 respondents revealed a very strong tendency for nurses to overlook a serious mistake by a close peer who had a reputation of being a “competent” nurse.

NICU nurses' lived experience: caring for infants with neonatal abstinence syndrome

PURPOSE

The primary aim of this qualitative methods study was to describe the lived experiences of neonatal intensive care unit (NICU) nurses with ethical and morally challenging issues.

SUBJECTS

The target population for the study was registered nurses working in the NICU. Interviews were completed with 16 nurses from 1 hospital.

DESIGN

A phenomenological method design was used to describe NICU nurses' lived experiences with ethical and moral issues encountered in the NICU.

METHODS

After obtaining signed consent, the principal investigator interviewed all participants, using a semistructured interview guide consisting of open-ended questions.

MAIN OUTCOMES

Ethical and moral distress related to neonatal abstinence syndrome was the predominant outcome.

PRINCIPAL RESULTS

Caring for infants, coping with families, and discharging infants home were the major concerns voiced by nurses in this study.

CONCLUSIONS

Nurses in this study struggled with issues of beneficence and nonmaleficence and were not aware of scientific evidence that guides methadone management of pregnant women.

Influencers of ethical beliefs and the impact on moral distress and conscientious objection

Considering a growing nurse shortage and the need for qualified nurses to handle increasingly complex patient care situations, how ethical beliefs are influenced and the consequences that can occur when moral conflicts of right and wrong arise need to be explored. The aim of this study was to explore influencers identified by nurses as having the most impact on the development of their ethical beliefs and whether these influencers might impact levels of moral distress and the potential for conscientious objection. Nurses whose ethical beliefs were most influenced by their religious beliefs scored higher in levels of moral distress and demonstrated greater differences in areas of conscientious objection than did nurses who developed their ethical beliefs from influencers such as family values, life and work experience, political views or the professional code of ethics.