Background No previous study has provided evidence for the scope and frequency of ethical dilemmas for paediatric nurses. It is essential to understand this to optimise patient care and tailor ethics support for nurses. Research aim The aim of this study was to explore the scope of nurses’ ethical dilemmas in a paediatric hospital and their engagement with the hospital clinical ethics service. Research design This study used a cross-sectional survey design. Participants and research context Paediatric nursing staff in a (...) tertiary paediatric centre in Australia completed an online survey asking about their exposure to a range of ethical dilemmas and their knowledge of the clinical ethics service. Analysis used descriptive and inferential statistics. Ethical considerations Ethical approval was granted from the hospital research committee. The survey was anonymous, and no identifying details of participants were collected. Results Paediatric nurses experienced a wide range of ethical dilemmas frequently, both in the intensive care and general areas. Knowledge and use of the clinical ethics service was poor and the most frequent challenge for nurses in managing dilemmas was feeling powerless. Conclusion There is a need to recognise the moral burden of ethical dilemmas for paediatric nurses in order to foster ethical sensitivity, and to provide adequate support to improve care and mitigate nursing moral distress. (shrink)

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly—often with lingering effects such as healthcare providers’ disengagement and moral distress (McAndrew et al. Journal of (...) Trauma Nursing 18(4):221–230, 2011), compromised inter-professional relationships (Rosenstein and O’Daniel American Journal of Nursing, 105(1):54–64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1–11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486–490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results. (shrink)

BackgroundThe phenomenon of ‘moral distress’ has continued to be a popular topic for nursing research. However, much of the scholarship has lacked conceptual clarity, and there is debate about what it means to experience moral distress. Moral distress remains an obscure concept to many clinical nurses, especially those outside of North America, and there is a lack of empirical research regarding its impact on nurses in the United Kingdom and its relevance to clinical practice.Research aimTo explore the concept of moral (...) distress in nursing both empirically and conceptually.MethodologyFeminist interpretive phenomenology was used to explore and analyse the experiences of critical care nurses at two acute care trauma hospitals in the United Kingdom. Empirical data were analysed using Van Manen’s six steps for data analysis.Ethical considerationsThe study was approved locally by the university ethics review committee and nationally by the Health Research Authority in the United Kingdom.FindingsThe empirical findings suggest that psychological distress can occur in response to a variety of moral events. The moral events identified as causing psychological distress in the participants’ narratives were moral tension, moral uncertainty, moral constraint, moral conflict and moral dilemmas.DiscussionWe suggest a new definition of moral distress which captures this broader range of moral events as legitimate causes of distress. We also suggest that moral distress can be sub-categroised according to the source of distress, for example, ‘moral-uncertainty distress’. We argue that this could aid in the development of interventions which attempt to address and mitigate moral distress.ConclusionThe empirical findings support the notion that narrow conceptions of moral distress fail to capture the real-life experiences of this group of critical care nurses. If these experiences resonate with other nurses and healthcare professionals, then it is likely that the definition needs to be broadened to recognise these experiences as ‘moral distress’. (shrink)

Within this paper, we discuss Moral Distress Reflective Debriefs as a promising approach to address and mitigate moral distress experienced by healthcare professionals. We briefly review the empirical and theoretical literature on critical incident stress debriefing and psychological debriefing to highlight the potential benefits of this modality. We then describe the approach that we take to facilitating reflective group discussions in response to morally distressing patient cases (“Moral Distress Reflective Debriefs”). We discuss how the debriefing literature and other clinical ethics (...) activities influenced the development of our approach. In particular, we focus on the role of the clinical ethicist as a facilitator with particular emphasis on encouraging perspective-taking and nurturing ethical attunement in a supportive manner. We suggest that this approach reduces the narrowing effects of frustration and anger that are often reported when individuals experience moral-constraint distress. Finally, we provide an example of Moral Distress Reflective Debriefs, elucidating how this supportive process complements ethics consultation and can mitigate the negative effects of moral distress. (shrink)

Austerity, by its very nature, imposes constraints by limiting the options for action available to us because certain courses of action are too costly or insufficiently cost effective. In the context of healthcare, the constraints imposed by austerity come in various forms; ranging from the availability of certain treatments being reduced or withdrawn completely, to reductions in staffing that mean healthcare professionals must ration the time they make available to each patient. As austerity has taken hold, across the United Kingdom (...) and Europe, it is important to consider the wider effects of the constraints that it imposes in healthcare. Within this paper, we focus specifically on one theorised effect—moral distress. We differentiate between avoidable and unavoidable ethical challenges within healthcare and argue that austerity creates additional avoidable ethical problems that exacerbate clinicians’ moral distress. We suggest that moral resilience is a suitable response to clinician moral distress caused by unavoidable ethical challenges but additional responses are required to address those that are created due to austerity. We encourage clinicians to engage in critical resilience and activism to address problems created by austerity and we highlight the responsibility of institutions to support healthcare professionals in such challenging times. (shrink)

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

Although moral distress is now a well-recognized phenomenon among all of the healthcare professions, few evidence-based strategies have been published to address it. In morally distressing situations, the “presenting problem” may be a particular patient situation, but most often signals a deeper unit- or system-centered issue. This article describes one institution’s ongoing effort to address moral distress in its providers. We discuss the development and evaluation of the Moral Distress Consultation Service, an interprofessional, unit/system-oriented approach to addressing and ameliorating moral (...) distress. (shrink)

Volume 19, Issue 11, November 2019, Page 85-87.

Background:Nurse managers are expected to continuously ensure that ethical standards are met and to support healthcare workers’ ethical competence. Several studies have concluded that nurses across various healthcare settings lack the support needed to provide safe, compassionate and competent ethical care.Objective:The aim of this study was to explore and understand how nurse managers perceive their role in supporting their staff in conducting ethically sound care in nursing homes and home nursing care.Design and participants:Qualitative individual interviews were performed with 10 nurse (...) managers with human resources responsibilities for healthcare workers in four nursing home wards and six home nursing care districts. Content analysis was used to analyse the data.Ethical considerations:The Norwegian Centre for Research Data granted permission for this study.Findings:The analysis resulted in seven subcategories that were grouped into three main categories: managers’ perception of the importance of the role, managers’ experiences of exercising the role and managers’ opportunities to fulfil the role. Challenges with conceptualizing ethics were highlighted, as well as lack of applicable tools or time and varying motivation among employees.Discussion:The leaders tended to perceive ethics as a ‘personal matter’ and that the need for and benefit of ethical support (e.g., ethics reflection) depended on individuals’ vulnerability, attitudes, commitment and previous experiences. The managers did not seem to distinguish between their own responsibility to support ethical competence and the responsibility of the individual employee to provide ethical care.Conclusions:Our findings suggest that nurse managers need support themselves, both to understand and to carry out their responsibilities to foster their staffs’ ethical conduct. Supporting staff in conducting ethically sound care requires more than organizing meeting places for ethical reflection; it also requires greater awareness and understanding of what ethical leadership means. (shrink)

Feelings of guilt are human emotions that may arise if a person committed an action that contradicts basic moral mores or failed to commit an action that is considered moral according to their ethical standards and values. Psychological scholarship distinguishes between altruistic guilt (AG) and deontological guilt (DG). AG results from having caused harm to an innocent victim, either by acting or failing to act, whereas DG is caused by violating a moral principle. Although physicians may be expected to experience (...) frequent feelings of guilt in their demanding and intensive work, it is surprising to find that this issue has not been explored in the professional literature on medical ethics. To that end, we conducted a qualitative study that included personal in-depth interviews with Sunni Muslim gynaecologists. These doctors provide underground infertility care and perform religiously forbidden treatments involving sex selection and gamete donation. They opened their hearts and spoke about the emotionally taxing pangs of conscience they suffer. Analysing their narratives led us to characterize their feelings of guilt as DG. We discuss the causes for their plight and the way they cope with it, compare DG to the concept of moral distress, and call for future research on clinicians’ feelings of guilt and pangs of conscience. (shrink)