Nurse Moral Distress and Ethical Work Environment

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

Exploring the Moral Distress of Registered Nurses

Registered nurses (RNs) employed in an urban medical center in the USA identified moral distress as a practice concern. This study describes RNs' moral distress and the frequency of morally distressing events. Data were collected using the Moral Distress Scale and an open-ended questionnaire. The instruments were distributed to direct-care-providing RNs; 100 responses were returned. Morally distressing events included: working with staffing levels perceived as `unsafe', following families' wishes for patient care even though the nurse disagreed with the plan, and continuing life support for patients owing to family wishes despite patients' poor prognoses. One high frequency distressing event was carrying out orders for unnecessary tests and treatments. Qualitative data analysis revealed that the nurses sought support and information from nurse managers, chaplaincy services and colleagues. The RNs requested further information on biomedical ethics, suggested ethics rounds, and requested a non-punitive environment surrounding the initiation of ethics committee consultations.

Nurses' satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses' experiences of well-being - a Norwegian study

BACKGROUND

Various studies have demonstrated that nursing is stressful and that the incidence of occupational stress-related burnout in the profession is high.

AIM

This descriptive-correlational study examined nurses' satisfaction with their psychosocial work environment, their moral sensitivity and differences in outcomes of clinical nursing supervision in relation to nurses' well-being by systematically comparing supervised and unsupervised nurses.

METHODS

Nurses were selected from two hospitals (n = 71). Data collection was by means of questionnaires and analysed by descriptive and inferential statistics.

RESULTS

The nurses' satisfaction with their psychosocial work environment was reflected in six factors: 'job stress and anxiety', 'relationship with colleagues', 'collaboration and good communication', 'job motivation', 'work demands' and 'professional development'. The nurses' perceptions of moral sensitivity comprised seven factors: 'grounds for actions', 'ethical conflicts', 'values in care', 'independence patient-oriented care', 'the desire to provide high-quality care' and 'the desire to provide high-quality care creates ethical dilemmas'. Nurses well-being were reflected in four factors 'physical symptom and anxiety', 'feelings of not being in control', 'engagement and motivation' and 'eye strain sleep disturbance'. The moral sensitivity 'ethical conflicts' were found to have mild negative correlations with psychosocial work environment 'job stress and anxiety professional development' and with 'total score' psychosocial work, moral sensitivity factor 'independence were correlated with psychosocial work factor 'relationships with colleagues' and 'total score', moral sensitivity were mildly correlated with 'collaboration and good communication and had a negative correlation to psychosocial work factor 'work demands'. In addition, significant correlations were found between the nurses' well-being profile and demographic variables, between 'engagement and motivation' and 'absence due to illness' and between 'time allocation for tasks', 'physical symptoms and anxiety' and 'age'. Mild significant differences were found between nurses attending and not attending group supervision and between 'physical symptoms and anxiety' and 'feelings of not being in control'.

CONCLUSIONS

We conclude that ethical conflicts in nursing are a source of job-related stress and anxiety. The outcome of supporting nurses by clinical nursing supervision may have a positive influence on their perceptions of well-being. clinical nursing supervision have a positive effect on nurses physical symptoms and their feeling of anxiety as well as having a sense of being in control of the situation. We also conclude that psychosocial work have an influence on nurses experience of having or not having control and their engagement and motivation.

Hospital Ethical Climates and Registered Nurses' Turnover Intentions

PURPOSE

To investigate (a) the effects of hospital ethical climates on positional and professional turnover intentions of registered nurses, and (b) the relationships among demographic factors, employment characteristics, and positional and professional turnover intentions of registered nurses.

DESIGN

A cross-sectional study of randomly selected registered nurses (n=463) in Missouri, USA, conducted in 2003 and 2004.

METHODS

A self-administered questionnaire containing the Hospital Ethical Climate Survey, the Anticipated Turnover Scale, and the Nursing Retention Index was used to assess registered nurses' perceptions of the hospital ethical climate and their intentions to leave their position or the nursing profession. Descriptive statistics, Pearson product-moment correlations, and hierarchical regression techniques were used to analyze the data.

FINDINGS

The hospital ethical climate explained 25.4% of the variance in positional turnover intentions and 14.7% of the variance in professional turnover intentions. Together, hospital ethical climate, control over practice, the use of educational reimbursement as a retention strategy, gender, and staff sufficiency explained 29.7% of the variance in positional turnover intentions. Hospital ethical climate, patient load, and control over practice together explained 15.8% of the variance in professional turnover intentions.

CONCLUSIONS

Of the variables included in this analysis, the hospital ethical climate was most important in explaining nurses' positional and professional turnover intentions.

Nursing competencies for spiritual care

AIM AND OBJECTIVES

The aim of this paper is to reveal the main nursing competencies for spiritual care, which emerged from data collecting from qualified nurses in Malta.

BACKGROUND

For nurses to deliver spiritual care, they must be competent to provide care on a physical, mental, social and spiritual level. As spiritual care may be influenced by culture, this study explored the competencies for spiritual care from the Maltese nurses' perspective.

METHODS

A descriptive exploratory study investigated nurses' competencies in the delivery of spiritual care to patients with myocardial infarction. Data were collected by means of an open-ended questionnaire on qualified nurses (n=77) followed by an in-depth interview on a stratified random sample (n=14) of nurses from the same respondents.

RESULTS

The four main nursing competencies identified were associated with the role of the nurse as a professional and as an individual person; delivery of spiritual care by the nursing process; nurses' communication with patients, inter-disciplinary team and clinical/educational organizations and safeguarding ethical issues in care.

CONCLUSION

This study demonstrated the complexity of spiritual care, which requires nurses to increase their awareness of the uniqueness of each individual patient with regard to the connection between mind, body and spirit; the assessment of the spiritual status of patients during illness and the implementation of holistic care as recommended by the Nursing Code of Ethics.

RELEVANCE TO CLINICAL PRACTICE

These findings will enable nurses to consider the importance of spiritual care, which may allow them to help empower patients find meaning and purpose during times of illness. More emphasis should be put on spiritual care in the pre- and postregistration education. Further research to translate these main competencies into specific competencies will guide spiritual care.

The relationship between moral distress and perception of futile care in the critical care unit

PURPOSE

Study the relationship between moral distress (MD) and futile care in the critical care unit (CCU).

SUBJECTS AND METHODS

A cross-sectional survey consisting of 38 clinical situations associated with MD related to 6 categories: physician practice, nursing practice, institutional factors, futile care, deception and euthanasia was distributed to 100 nurses at a single CCU. The intensity and frequency of MD were scored with Likert scale: 0-lowest and 6-highest.

RESULTS

The survey was completed by 44 (44%) nurses. Median age was 33 years, 80% females. Median intensity of MD was high for the six categories and had no relationship with age, time in CCU or nursing practice. The encounter frequency of MD for futile care was the highest and was significantly related to age >33 years (p=0.03), time in CCU >4 years (p=0.04) and nursing practice >7 years (p=0.01).

CONCLUSION

MD associated with clinical situations representing futile care increased with time in CCU. Future interventions are required to minimize the exposure to futile care situations and develop mechanisms to mitigate the effects of MD in the CCU.

Influenza pandemic and professional duty: family or patients first? A survey of hospital employees

Background

Conflicts between professional duties and fear of influenza transmission to family members may arise among health care professionals (HCP).

Methods

We surveyed employees at our university hospital regarding ethical issues arising during the management of an influenza pandemic.

Results

Of 644 respondents, 182 (28%) agreed that it would be professionally acceptable for HCP to abandon their workplace during a pandemic in order to protect themselves and their families, 337 (52%) disagreed with this statement and 125 (19%) had no opinion, with a higher rate of disagreement among physicians (65%) and nurses (54%) compared with administrators (32%). Of all respondents, 375 (58%) did not believe that the decision to report to work during a pandemic should be left to the individual HCP and 496 (77%) disagreed with the statement that HCP should be permanently dismissed for not reporting to work during a pandemic. Only 136 (21%) respondents agreed that HCW without children should primarily care for the influenza patients.

Conclusion

Our results suggest that a modest majority of HCP, but only a minority of hospital administrators, recognises the obligation to treat patients despite the potential risks. Professional ethical guidelines allowing for balancing the needs of society with personal risks are needed to help HCP fulfil their duties in the case of a pandemic influenza.

Unable to answer the call of our patients: mental health nurses' experience of moral distress

When health practitioners' moral choices and actions are thwarted by constraints, they may respond with feelings of moral distress. In a Canadian hermeneutic phenomenological study, physicians, nurses, psychologists and non-professional aides were asked to identify care situations that they found morally distressing, and to elaborate on how moral concerns regarding the care of patients were raised and resolved. In this paper, we describe the experience of moral distress related by nurses working in mental healthcare settings who believed that lack of resources (such as time and staff) leads to dispiritedness, lack of respect, and absence of recognition (for both patients and staff) which severely diminished their ability to provide quality care. The metaphors of flashlight and hammer are used to elaborate nurses' possible responses to intolerable situations.

"Futile" care: do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses

PURPOSE

To qualitatively explore the process of the provision of futile care in Canadian intensive care units (ICUs).

MATERIALS AND METHODS

A mailed, semistructured survey was sent to medical and nursing unit directors of all Canadian ICUs, asking them to estimate the frequency of provision of futile care, when care becomes "futile," the reasons such care is provided, and the resources that are available to help make end-of-life decisions. Nurse/physician agreement was assessed by chi(2) analysis or Fisher exact test. Content analysis to identify common themes was carried out by 4 raters using a Delphi process.

RESULTS

The response rate was 72%. The majority reported futile therapy had been provided in their ICU over the last year (nurses, "N"=95%, physicians, "P"=87%, P=.02). The most commonly stated reasons for providing futile care were family request (N=91%, P=91%, P=NS) and attending physician request (N=91%, P=87% P=NS). Physicians were cited to provide futile care because of prognostic uncertainty (N=73%, P=84%, P=.047) and legal pressures (N=84%, P=75%, P=NS). Comment review revealed 8 main reasons why futile care was provided, the most common of which were that "death was perceived as treatment failure," and poor provider-family communication. Few providers were aware of societal (N=26%, P=51%) or local (22%, all) guidelines relating to the provision of futile care, but of those who were aware, the majority found these useful (range, 73%-74%). Twenty-seven percent expressed the need for someone to discuss difficult ethical issues, such an individual with ethics training specifically assigned to the ICU.

CONCLUSIONS

Caregivers voice the opinion that provision of futile care occurs, for multiple reasons, not the least of which is provider-driven. Nurses and physicians of Canadian ICUs perceive the need for increased availability of more ICU-directed and ethically trained resources to help them in providing end-of-life care.

Long-Term Nursing Care of Elderly People: Identifying ethically problematic experiences among patients, relatives and nurses in Finland

The aim of this study was to explore ethically problematic situations in the long-term nursing care of elderly people. It was assumed that greater awareness of ethical problems in caring for elderly people helps to ensure ethically high standards of nursing care. To obtain a broad perspective on the current situation, the data for this study were collected among elderly patients, their relatives and nurses in one long-term care institution in Finland. The patients (n=10) were interviewed, while the relatives (n=17) and nurses (n=9) wrote an essay. Interpretation of the data was based on qualitative content analysis. Problematic experiences were divided into three categories concerning patients’ psychological, physical and social integrity. In the case of psychological integrity, the problems were seen as being related to treatment, self-determination and obtaining information; for physical integrity, they were related to physical abuse and lack of individualized care; and for social integrity, to loneliness and social isolation. This study provided no information on the prevalence of ethical problems. However, it is clear from the results that patient integrity warrants more attention in the nursing care of elderly patients.

Knowledge, attitudes and practice of healthcare ethics and law among doctors and nurses in Barbados

Background

The aim of the study is to assess the knowledge, attitudes and practices among healthcare professionals in Barbados in relation to healthcare ethics and law in an attempt to assist in guiding their professional conduct and aid in curriculum development.

Methods

A self-administered structured questionnaire about knowledge of healthcare ethics, law and the role of an Ethics Committee in the healthcare system was devised, tested and distributed to all levels of staff at the Queen Elizabeth Hospital in Barbados (a tertiary care teaching hospital) during April and May 2003.

Results

The paper analyses 159 responses from doctors and nurses comprising junior doctors, consultants, staff nurses and sisters-in-charge. The frequency with which the respondents encountered ethical or legal problems varied widely from 'daily' to 'yearly'. 52% of senior medical staff and 20% of senior nursing staff knew little of the law pertinent to their work. 11% of the doctors did not know the contents of the Hippocratic Oath whilst a quarter of nurses did not know the Nurses Code. Nuremberg Code and Helsinki Code were known only to a few individuals. 29% of doctors and 37% of nurses had no knowledge of an existing hospital ethics committee. Physicians had a stronger opinion than nurses regarding practice of ethics such as adherence to patients' wishes, confidentiality, paternalism, consent for procedures and treating violent/non-compliant patients (p = 0.01)

Conclusion

The study highlights the need to identify professionals in the workforce who appear to be indifferent to ethical and legal issues, to devise means to sensitize them to these issues and appropriately training them.

Perceptions of "futile care" among caregivers in intensive care units

BACKGROUND

Many caregivers in intensive care units (ICUs) feel that they sometimes provide inappropriate or excessive care, but little is known about their definition of "futile care" or how they attempt to limit its impact. We sought to explore how ICU staff define medically futile care, why they provide it and what strategies might promote a more effective use of ICU resources.

METHODS

Using semi-structured interviews, we surveyed 14 physician directors, 16 nurse managers and 14 respiratory therapists from 16 ICUs across Ontario. We analyzed the transcripts using a modified grounded-theory approach.

RESULTS

From the interviews, we generated a working definition of medically futile care to mean the use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment. Respondents felt that futile care was provided because of family demands, a lack of timely or skilled communication, or a lack of consensus among the treating team. Respondents said they were able to resolve cases of futile care most effectively by improving communication and by allowing time for families to accept the reality of the situation. Respondents felt that further efforts to limit futile care should focus on educating the public and health care professionals about the role of the ICU and about alternatives such as palliative care; mandating early and skilled discussion of resuscitation status; establishing guidelines for admission to the ICU; and providing legal and ethical support for physicians who encounter difficulties. There was a broad consistency in responses among all disciplines.

INTERPRETATION

ICU physicians, nurses and respiratory therapists have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU.

Nurses' feelings and thoughts about using physical restraints on hospitalized older patients

AIM

To explore nurses' feelings and thoughts about physically restraining older hospitalized patients.

BACKGROUND

The use of physical restraints is still highly prevalent in hospitals; furthermore, older patients are most likely to be so restrained. Studies in acute care settings have focused mainly on nurses' knowledge, attitudes, or practice concerning physical restraints, on physical restraint reduction programmes, on nurses' perceptions about the use of physical restraints, or on elderly patients' experiences with physical restraints. To the best of our knowledge no studies have been conducted on hospital nurses' feelings and thoughts about the use of physical restraints in Taiwan.

DESIGN AND METHODS

A qualitative approach was used to understand this phenomenon. Semi-structured interviews were carried out, from August 2002 to March 2003, with 12 nurses working in three hospitals. The interviews were audiotaped and transcribed verbatim; content analysis was used to analyse the data.

RESULTS

Nurses reported a variety of emotional responses regarding the use of physical restraints, including sadness, guilt, conflicts, retribution, absence of feelings, security, and pity for the restrained older people. Rationalization, sharing with colleagues, and compensating behaviours were ways that nurses used to manage their negative feelings.

CONCLUSIONS

Most nurses had negative feelings towards the use of physical restraints. Among these nurses there was a struggle between patients' autonomy and the practice of care. However, other nurses said they had 'no feelings' or 'feeling of security' while using physical restraints.

RELEVANCE TO CLINICAL PRACTICE

The findings of this study may contribute to filling the gaps in nursing knowledge, to improving protocols for physical restraint use in hospitals, and may also assist nurse managers to create a supportive practice environment. It is recommended that in-service training programmes should cover misconceptions regarding physical restraint use, ethical issues and how to cope with feelings while using physical restraints.

Nurses' ethical perceptions about coercion

PURPOSE OF THE STUDY

The purpose of this study was to describe Finnish psychiatric nurses' ethical perceptions about coercive measures in acute psychiatric setting.

METHODS

The data were collected with a questionnaire developed for this study. The sample included 170 Finnish psychiatric nurses on acute wards in five psychiatric hospitals. The data were analysed using frequency and percentage distributions, mean and standard deviations. The internal consistency of the instrument was explored with Cronbach's alpha. The association between the background variables and the sum score of the items of the questionnaire was tested with Mann-Whitney U-test and Kruskal-Wallis test. The open-ended question was analysed with content analysis.

RESULTS

Some psychiatric nurses perceived coercive measures as ethically problematic. In particular, the implementation of forced medication (18%), four-point restraints (16%) and patient seclusion (11%) were perceived as ethically problematic. Female nurses and nurses who worked on closed wards perceived the measures to be more problematic than male nurses and nurses who did not work on closed wards.

CONCLUSION

In Finland, special attention has been paid to ethical questions related to the care of psychiatric patients and to the enhancement of patients' rights, yet the majority of the nurses participating in the survey did not perceive coercive measures as ethically problematic. More research on this issue as well as further education of the personnel and more extensive teaching of ethics in nursing schools are needed to support the ability of the psychiatric personnel to identify ethically problematic situations. In addition, it is important to consider new measures for generating genuine moral reflection among the personnel on the usage of coercive measures as well as on their effectiveness and legitimacy in the psychiatric care.

Distressing situations in the intensive care unit: a descriptive study of nurses' responses

Moral distress is a significant stressor for nurses in critical care. Feeling that they are doing the "right thing" is important to nurses, and situations of moral distress can make them question their work. The purpose of this study was to describe critical care nurses' levels of moral distress, the effects of that distress on their personal and professional lives, and nurses' coping strategies. The study consisted of open-ended questions to elicit qualitatively the nurses' feelings about moral distress and a quantitative measure of the degree of distress caused by certain types of situations. The questionnaires were then analyzed to assess the nurses' opinions regarding moral distress, how their self-perceived job performance is affected, and what coping methods they use to deal with moral distress. The most frequently encountered moral distress situations involved critically ill patients whose families wished to continue aggressive treatment when it probably would not benefit the patient in the end.

Navigating moral distress using the moral distress map

The plethora of literature on moral distress has substantiated and refined the concept, provided data about clinicians' (especially nurses') experiences, and offered advice for coping. Fewer scholars have explored what makes moral distress moral If we acknowledge that patient care can be distressing in the best of ethical circumstances, then differentiating distress and moral distress may refine the array of actions that are likely to ameliorate it. This article builds upon scholarship exploring the normative and conceptual dimensions of moral distress and introduces a new tool to map moral distress from emotional source to corrective actions. The Moral Distress Map has proven useful in clinical teaching and ethics-related debriefings.

The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses

Studies among physicians and nurses in paediatric care reveal experiences of loneliness and lack of open dialogue. The aim of this study was to illuminate the meaning of female Registered Nurses' lived experience of being in ethically difficult care situations in paediatric care. Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the 'uninteresting' patients. This may be understood as ethics of memory where their conscience 'set them a test'. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture. The rules and the routines of the caring culture represented structural barriers for creating open dialogue and an ethically justifiable practice, called inauthentic existence, blindness related to our own inauthentic understanding, which focuses on the routines, rules, theories and systems.

Meeting Ethical Challenges in Acute Nursing Care as Narrated by Registered Nurses

Five registered nurses were interviewed as part of a comprehensive investigation by five researchers into the narratives of five enrolled nurses (study 1, published in Nursing Ethics 2004), five registered nurses (study 2) and 10 patients (study 3) describing their experiences in an acute care ward at one university hospital in Sweden. The project was developed at the Centre for Nursing Science at Ö rebro University Hospital. The ward in question was opened in 1997 and provides care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The registered nurses were interviewed concerning their experience of being in ethically difficult care situations in their work. Interpretation of the theme ‘ethical problems’ was left to the interviewees to reflect upon. A phenomenological hermeneutic method (inspired by the French philosopher Paul Ricoeur) was used in all three studies. The most prominent feature revealed was the enormous responsibility present. When discussing their responsibility, their working environment and their own reactions such as stress and conscience, the registered nurses focused on the patients and the possible negative consequences for them, and showed what was at stake for the patients themselves. The nurses demonstrated both directly and indirectly what they consider to be good nursing practices. They therefore demand very high standards of themselves in their interactions with their patients. They create demands on themselves that they believe to be identical to those expected by patients.

Bridging the Gap: a study of general nurses’ perceptions of patient advocacy in Ireland

Advocacy has become an accepted and integral attribute of nursing practice. Despite this adoption of advocacy, confusion remains about the precise nature of the concept and how it should be enacted in practice. The aim of this study was to investigate general nurses’ perceptions of being patient advocates in Ireland and how they enact this role. These perceptions were compared with existing theory and research on advocacy in order to contribute to the knowledge base on the subject.

An inductive, qualitative approach was used for this study. Three focus group interviews with a total of 20 practising nurses were conducted with a sample representing different grades in a general hospital setting. Data analysis was carried out using elements of Strauss and Corbins’ approach to concept development. The findings indicate that the principal role of the nurse advocate is to act as an intermediary between the patient and the health care environment. The results highlight that advocacy did, however, result in nurses becoming involved in conflict and confrontation with others and that it could be detrimental to nurses both professionally and personally. It was also clear that when enacting advocacy, nurses distinguished between ‘clinical advocacy’ (acting directly for patients in the clinical environment) and organizational advocacy (acting on an organizational level for one or more patients).

Nursing is different than medicine: ethical difficulties in the process of care in surgical units

AIM

This paper describes a study of the kinds of ethical difficulties nurses face in the process of care in surgical units.

BACKGROUND

Nurses face ethically difficult situations in trying to find the most appropriate actions to take for patients. Differences of opinion with doctors about the treatment and care of patients and conflicts between nurses' value systems and those in the organization where they are employed are described as sources of ethical difficulty. Nurses experience moral distress when institutional constraints restrict them from carrying out appropriate moral actions.

METHODS

Ten female nurses working in surgical units at one university hospital in Norway were interviewed as part of a comprehensive investigation into the narratives of nurses and doctors about being in ethically difficult situations. The transcribed interview texts were subjected to a phenomenological-hermeneutic interpretation. The study was conducted during 2004.

FINDINGS

The main ethically difficult care situations described by the nurses concerned being open and honest, trusting patients' complaints, and creating limits to their involvement. Differences in opinion with doctors about the treatments, the absence of doctors in the unit and limited interest in holistic treatment and care resulted in nurses not receiving the medical orders they needed. A heavy workload, lack of time and staffing problems resulted in difficult ethical prioritizations and reduced standards of care. Shared rooms and beds in the corridors made it difficult to preserve patients' rights to privacy and confidentiality.

CONCLUSION

Interventions and investments are needed to improve the work environment of nurses, especially modifying the job constraints of the work environment. The moral responsibility for upholding the quality of care in surgical services and hospital performance should be more equally distributed between nurses, doctors and hospital managers. Discussions and collaboration between and within healthcare disciplines and managers should be initiated to establish shared moral understanding of the standards of care in hospitals.

Ethical issues in participatory action research

The purpose of this article is to describe the ethical issues arising out of participatory action research (PAR), on the basis of both an empirical study and the research literature, and to discuss how to deal with these issues. The data consist of the experiences and results of three phases of PAR relating to orthopaedic patients with rheumatoid arthritis (RA) and the analysis of 20 articles on the ethics of action research. As a result, the following ethical issues and the ways to treat them were discussed: informed consent, confidentiality and anonymity, protecting an individual from harm, the role of the researcher, the location of 'power' in PAR, and the ownership of the research. The flexibility of PAR in use and its main features are also related to the decisions made and actions taken in response to ethical issues. It is particularly important in PAR to proceed according to the participants, and to involve them from the beginning of the process, in order to insure the equal balance of power between participants and researcher.

Palliative care delivery in the NICU: what barriers do neonatal nurses face?

Despite the existence of a universal protocol in palliative care for dying babies and their families, provision of this type of care remains ad hoc in contemporary neonatal settings. Influential bodies such as the American Academy of Pediatrics and the World Health Organization support palliative care to this patient population, so why are such measures not universally adopted? Are there barriers that prevent neonatal nurses from delivering this type of care? A search of the literature reveals that such barriers may be significant and that they have the potential to prevent dying babies from receiving the care they deserve. The goal of this literature review is to identify these barriers to providing palliative care in neonatal nursing. Results of the research have been used to determine item content for a survey to conceptualize and address these barriers.

Meeting Ethical Challenges in Acute Care Work as Narrated by Enrolled Nurses

Five enrolled nurses (ENs) were interviewed as part of a comprehensive investigation into the narratives of registered nurses, ENs and patients about their experiences in an acute care ward. The ward opened in 1997 and provides patient care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The ENs were interviewed concerning their experience of being in ethically difficult care situations and of acute care work. The method of phenomenological-hermeneutic interpretation inspired by the French philosopher Paul Ricoeur was used. The most prominent feature was the focus on relationships, as expressed in concern for society’s and administrators’ responsibility for health care and the care of older people. Other themes focus on how nurse managers respond to the ENs’ work as well as their relationships with fellow ENs, in both work situations and shared social and sports activities. Their reflections seem to show an expectation of care as expressed in their lived experiences and their desire for a particular level and quality of care for their own family members. A lack of time could lead to a bad conscience over the ‘little bit extra’ being omitted. This lack of time could also lead to tiredness and even burnout, but the system did not allow for more time.

Sensitivity to Ethical Issues Confronted by Korean Hospital Staff Nurses

This descriptive study was undertaken to identify the degree of ethical sensitivity of staff nurses and to analyze the differences in ethical sensitivity in terms of both general and ethics-related characteristics. Participants were 236 staff nurses working in general hospitals in Korea. Ethical sensitivity was measured by means of an instrument developed by the researchers. The results showed that the mean score for the degree of ethical sensitivity was 0.71 out of a possible maximum score of 1 (range 0.30 to 0.97). For general characteristics, there was a significant difference in ethical sensitivity according to age (F (df 2233)-3.99, P-0.02). For characteristics related to ethics, there was a significant difference in ethical sensitivity according to attitude towards the nursing profession (F (df 4231)-2.94, P-0.03). It is therefore recommended that a training program reflecting these variables be developed to enhance staff nurses’ ethical sensitivity.

Self-state of nurses in caring for SARS survivors

The aim of this study was to analyze nurses' experiences of role strain when taking care of patients with severe acute respiratory syndrome (SARS). We adopted an interpretive/ constructivist paradigm. Twenty-one nurses who had taken care of SARS patients were interviewed in focus groups. The data were analyzed using thematic analysis. The self-state of nurses during the SARS outbreak evolved into that of professional self as: (1) self-preservation; (2) self-mirroring; and (3) self-transcendence. The relationship between self-state and reflective practice is discussed.