From painful busyness to emotional immunization: Nurses’ experiences of ethical challenges

Introduction

In this article, ethical challenges refer to values that entail emotional and moral stress in healthcare personnel. The challenges are related to provision of professional care for patients. The professional values presented in ethical guidelines of the Norwegian Nurses Organisation (NNO) and International Council of Nurses (ICN) ¹ describe nurses’ professional ethics and the obligations that pertain to good nursing practice. The foundation of all nursing is respect for life and the inherent dignity of the individual. Nursing is to be knowledge-based and founded on ethical values such as compassion, care, and respect for human rights. The focus on caring, particularly for vulnerable people, establishes the ethical dimension of nursing practice. ¹ The nurse has a personal responsibility to ensure that his or her own practice is professionally, ethically, and legally accountable. Although a set of principles and rules are vital to human conduct, one cannot wholly depend on such principles for guidance since they can never be complete enough to answer all issues involving moral decisions. ² This study will explore how nurses understand ethical challenges in daily care. Moreover, a literature search using the keywords ‘ethical challenges’ did not turn up a large set of articles, whereas the keyword ‘ethical issues’ turned up several articles.

Research proposes that nurses lack insight in ethical competence that permits them to identify ethical dilemmas and that ethical issues are rarely discussed on the wards. ^{3 –5} De Casterlé et al. ⁶ claim that nurses encounter ethical dilemmas in using conventions. The conclusion highlights the urgent need to change nurses’ attitudes toward an individual, patient-centered vision. Personal and professional skills are necessary to carry out difficult ethical decisions in practice. Thorup et al. ⁷ assert that there is no recipe for nursing as a moral practice. The nurse is obliged to put herself at risk in order to accommodate ethical demands placed on her as a professional and preserve the vulnerable trust relationship that is crucial for cooperation with the patient. The challenge for the nurse is to understand that the trust and power inherent in her encounter with patient entail a mandate to be attentive. For some time, research confirmed that nurses experience moral distress (MD) in their daily work and that this became a major problem for the nursing profession. ^3,4,8,9 The problem seems to affect nursing in all healthcare systems. One of the studies underlines that younger nurses and those with less experience encounter ethical issues more frequently and report higher levels of stress. Nursing Ethics Number 1, ¹⁰ 2015, gathered a number of selected papers in order to examine the relationship of MD to a host of important variables in the work life of nurses. The aim was to expand the international focus on research, suggesting interventions to prevent and reduce MD and debating the relevance of MD as a concept.

Moreover, the nurse’s ethical challenge to meet patients’ fundamental care needs is complex. Nurses frequently make ethical decisions during their work, although they may not be aware of doing so. To retain nurses in the profession, targeted ethics-related interventions are needed that address caring for an increasingly complex patient population. Kitson et al. ¹¹ identified three challenges: the need for integration, the need to focus on relationships, and the need for a systematic approach to a research agenda that evaluates basic nursing care interventions and effective relationships within the wider context of the healthcare environment. Goethals et al. ¹² found in their literature review that nurses’ ethical practice is a complex process of reasoning, decision-making, and implementation of the decision in practice. The decision-making is influenced by personal and contextual factors such as difficult work environment. Some studies have cited the work environment’s influence on nurses’ ethical care delivery. ^5,12 Nurses report different influences, such as high frequency of ethically sensitive situations; however, they experience poor ethical support and scarcity of ethical training programs. According to Atabay et al., ⁵ cultural characteristics are reflected in MD scale and the ethical climate scale. Nevertheless, the ethical guidelines present what society can expect from nurses. Ethical challenges and ethical responsibilities in nursing need further exploration. Increased insight in these issues may contribute to knowledge about how to improve ethical practice.

Aim

The purpose of this article is to gain a deeper understanding of how nurses face ethical challenges in daily practice. The chosen research question is “What ethical challenges do nurses experience in their daily practice?”

Method

Study sample

Nine qualified female nurses from three different wards were interviewed about their experiences concerning ethical issues. The inclusion criteria stipulated a minimum of 2 years of experience and an interest in the theme. Ages ranged between 25 and 57 years. Four respondents had special training for nurses such as clinical specialist, palliative care, evidence-based practice, and cardiology (Figure 1). The interviews were carried out based on a thematic guide and were tape-recorded. The period for the interviews was during the autumn of 2013.

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Figure 1.

Age and education of the participants.

Results

The participants presented their experiences openly and expressed gratitude that someone took time to listen to them. In the course of the hermeneutical process, four key themes emerged: (1) “the painful busyness,” (2) “a conflict concerning values,” (3) “compromising with professional principles,” and (4) “emotional immunization.”

Emotional immunization

The nurses expressed that they could identify the ethical challenges; however, they considered themselves unable to address them because of the circumstances. Thus, they adopted an attitude of disregard that the fact that they did not shield the patient from view while care was given seemed to them to be a difficult issue; however, they seemed to get used to it. Simultaneously, they seemed to prioritize tasks demanded by the system and at the expense of their own professional values. Thus, professional nursing values seemed to fade and even vanish in the process of adapting to the existing culture. The following statement shows how the nurse describes her change in behavior in order to cope:

Yes, I get tired sometimes. However, I used to be much more tired some years ago, because then I cared about it. When I got back home, I thought, “Good Lord, today we had a conversation while another patient was listening” for example. Nevertheless, in the course of time, you learn to ignore some of the feelings. Therefore, you learn almost to ignore the feeling that OK, ethics is not that important. Of course, it is terrible. It definitely is, but after a while, you do not bother. In the end, you will find that there are other things to worry about instead. In addition, it is tragic. (Nurse 2)

Neglecting fundamental needs as well as observing patients’ dignity being violated, patients received full medical treatment until the time of death, without speaking out or showing any affection is seen as a frightening development. Another nurse expresses her survival strategy like this:

We violate confidentiality constantly all day, in every room, for all patients. And staying in this world, I become a little indistinguishable, in a way. (Nurse 1)

Another nurse described her lack of compassion for a patient who complained:

Patients are different. Many times I wonder … There once was a patient suffering from a perforated appendix. He had surgery. Returning to the ward, he shared a room with a patient suffering from advanced cancer and who was expected to die very soon. The one with appendicitis was so demanding, complaining about everything. I thought to myself, he is ill, but I wish he knew the situation of the patient in the bed beside him. Maybe he would stop complaining. I did not say anything, but my thoughts… Anyway, he is supposed to get proper nursing care too, but … (Nurse 6)

Another kind of reaction is described in conjunction with showing irritation for a patient:

It scares me that when the corridor is full and a patient arrives and he says things like, “Why don’t I get a room?” and you answer “Why? Can’t you see that the hallway here is full? Haven’t you read what’s in the media in recent years, like?” You become almost a bit like that, even though I cannot expect that a patient will think like me. Yes, it is a bit scary that you almost start thinking like that because it is my everyday life. (Nurse 5)

In summary, when nurses get used to the routines and the culture on the wards, they learn not to get involved. There seem to be a process going on in the nurses’ minds from being idealistic and self-critical to becoming morally blinded and emotionally immune. Emotional immunization emerged as a new exploration in the process of adapting. It refers to staying unaffected as far as patient’s fundamental needs are concerned. We present Figure 2 showing the different steps in the process.

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Figure 2.

The systematic steps of the interpretation.

Discussion

The hermeneutic quest in this study was to understand the ontological meaning of ethical challenges that nurses experience during their working day. To reach a deeper understanding, we recognized the meaning of the text by engaging with it in textual explication and interpretation, by entering into a dialogical relationship. This may be understood as Gadamer’s ¹⁴ “fusion of horizons.” Through the work of interpretation, the meaning of the participants’ experiences became richer and we participated in the production of a more encompassing context of meaning. Finally, we gained an expanded and more profound understanding.

The discussion will describe the results as deriving from a systematic development starting out with experiencing busyness as a painful phenomenon that leads to conflicts about ethical values. The next step will present the consequences compromising professional principles for nursing care and finally ending up in being morally blinded and emotionally immune. The nurses in the study were concerned about ethics when they were asked about it. They were engaged in ethical values such as shielding while caring, keeping the oath of confidentiality, and caring for the whole person. Despite this, they described themselves as being too busy to find time to practice their ethical values. The busyness appeared to reveal a feeling of powerlessness at being unable to improve their situation. This was understood as painful, characterized by not being able to do what they intended to do according to their values, accompanied by no time for reflection. The situation seemed to cause poor control concerning how to view and prioritize clinical issues. This is interpreted as a lack of ethical value congruency and a cause of MD. Jameton and Mauksch ¹⁵ define MD as the painful psychological disequilibrium that results from recognizing the ethically appropriate action, yet not taking it, because of obstacles such as lack of time, supervisory reluctance, an inhibiting medical power structure, institution policy, or legal considerations. Corley ⁴ claims that MD arises when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action. These views are in accordance with the results of this study.

This study also refers to the environment or culture in which the nurses are a part. The culture consisted of nurses with varying clinical experience. The experienced nurses expressed their worries concerning the young and inexperienced nurses. They would like them to experience the meaning of a close relationship to the patient. They themselves characterized this as a unique professional satisfaction. However, they observed what they called an alienation of the patient. The feeling of well-being was not emphasized. The patient did not receive his daily physical care, the bed was not changed, and the nurse seemed to prioritize tasks concerning documentation and filling out forms on the computer. This is understood as a cultural weakness. According to Atabay et al., ⁵ cultural characteristics are reflected in both the MD scale and the ethical climate scale. Regarding ethical climate, different types appear as rules, well-being of stakeholders, individualism, and organizational interests. In order to cope with ethical conflicts in values, the nurses seemed to adapt to the existing culture. The culture appeared to prioritize tasks requested by the physicians, such as medication, documentation, blood samples, and blood pressure. Accordingly, these are crucial tasks within nursing responsibility when it comes to medical treatment and clinical observations of the patient. Weak scientific, professional foundation appears to entail adaptation of existing systems, ¹⁶ and we found traces of this in this study. However, satisfying fundamental needs is considered to be a paramount concern for nursing care, a concern that is neither attended to by other professional groups nor asked for verbally by patients. In the course of adapting, caregivers assigned low priority to issues such as caring for fundamental needs and bolstering the feeling of well-being in patients. The determination not to prioritize oral hygiene for the patients was attributed to shortage of time and insufficient number of staff, not whether the provision was ethical and involves negative consequences for the patient.

Nurses’ ethical practice is a difficult and complex process in which an intricate web of personal and contextual factors plays a role in the reasoning and behavioral process. ⁴ Martinsen ¹⁷ claims that there is a general pressure to make the professional more efficient, able to standardize and keep an overview of complex situations, and keep up with an increasing demand for data documentation. At the same time, the same professional is supposed to pay attention to the patient and his or her situation. Nursing is thus computationally intensive and can lead to moral stress. The participants did not seem to have a tradition for reflecting over ethical challenges in their daily care. They seemed to experience being trapped in a system where ethical ideals were not on the agenda. They appeared to experience a growing frustration over the lack of an opportunity to think about ethical challenges and instead having to prioritize tasks that were required. Consequently, basic professional principles such as providing information and encouraging patients were forgotten. Not being able to provide the care the patients need may contribute to creating a distance between patient and caregiver and pave the way for emotional immunization. This is understood as a growing conflict within their minds, conscious and unconscious. However, the participants replied that they generally found that the patients received satisfactory nursing when they were asked to characterize the daily care. This is understood as a paradox and a kind of blinding in terms of the total situation.

Research shows that MD leads to a conflict of values. ¹² A quantitative literature review revealed that many nurses experience MD with difficult care situations and suffer burnout. This can have an impact on their professional position. ¹⁸ MD prevents nurses from taking appropriate action; Johnstone and Hutchinson ¹⁹ discuss whether MD is fact or artifact. They refer to other healthcare providers being under pressure from different kinds of constraints in varying degrees, and they ask why nurses should constitute a special case because of their inability to attend to their personal responsibilities. They claim that there is a risk that MD discourse may become an apology for nurses relinquishing their moral responsibility to perform as moral professionals. Furthermore, they argue for abandoning the concept in nursing ethics discourse and instead make the case for improving moral thinking and conduct in nursing and healthcare domains. This study finds that management seems to be inadequate, as the professional and ethical dimension is not ensured in relation to the duty of confidentiality. According to Martinsen, ²¹ perception may have difficult applications in the healthcare system. The patient may be overwhelmed by chaotic impressions while he is trapped in his own body, filled with pain and feelings that are difficult to verbalize. The nurse may lose her self-control through not being in touch with her own feelings and affections in the situation. There may be a sensual distance both to the patient and to herself. Martinsen calls this to be absent. Ethical behavior implies a continuous rethinking of one’s own attitudes and oneself.

Emotional immunization emerged as new exploration in this study. Traditionally, immunization refers to a medical process. However, in this study, it involves moral blindness as well as being resistant against impressions. It seems to result from adapting to poor professional delivery of care and not being able to improve management. The nurses expressed a type of gradual resignation, and their critical awareness seemed to disappear. The culture did not ask for critical thinking, but rather obedience to current decision-making. According to Martinsen, ¹⁷ the professional is not always sensually present. In such a state of mind, the professional is not able to observe the vulnerability of the patient. While in the throes of busyness, the professionals may block out both their own and others’ vulnerability. Martinsen presents what she calls “an unpleasant” and “a pleasant busyness.” The “unpleasant busyness” is culturally determined by priorities, norms, and duties imposed on the professional—to work under pressure without joy—whereas the “pleasant busyness“ emerges when professionals take care of the “other man’s” life. The professional is busy according to what he owes “the other.” She calls this an ontological busyness. This kind of busyness requires self-reflection and self-care. Furthermore, she claims that the “busy busyness” is a way of hiding feelings of guilt and involves self-protection as well as exclusion of liability. The nurse faces a moral conflict because she is not able to provide the patient with optimal care. This leads to MD. There is a lot of guilt and disclaimers in the “pace of the busyness,” she claims. This stress is attenuated by a hectic bustle providing less guilt. A hectic bustle providing less guilt tries to prevent the distress. This inhibits the professional in seeing clearly. However, the feeling of shame, both the ontological and the one inflicted by culture requirements, will increase because of busyness leading to a vicious circle. ¹⁷ The circle will be hard to exit. This may explain why emotional immunization may occur and why it is morally devastating both for the individual nurse and for the professional culture of nursing. In addition, it may lead to adverse and serious consequences for the patient.

Martinsen ^20,21 describes the nurse as a professional when she is guided by her perception in her encounter with the patient, using her professional thinking in interpreting the patient. The contemplation of reflection is effective, she claims. Thorup et al. ⁷ claim that there is no recipe for nursing as a moral practice. In the presence of the patient, it is crucial that the nurse develops an intentional mindfulness and attentiveness toward the concrete situation in order to project a personal presence. What is needed is the courage, when confronting the patients’ suffering, to invest part of oneself in the encounter with the patient. The nurses’ orientation makes a difference. If she prioritizes taking care of basic needs, she may overlook the life phenomena and connected problems; there is a risk of creating a distance that may restrict the patients’ space for action. Thus, there is a need for systematic ethics educational activities for improving the capacity of nurses to manage ethical issues in patient care.

Conclusion

The study showed that the participants at the outset were idealistic and concerned about ethical challenges. However, in the course of time, this way of thinking changed. The healthcare providers seemed to undergo a process leading to emotional immunization. Emotional immunization occurred as a new dimension/nuance involving moral blindness and immunity in relation to be touched. This situation may entail serious consequences when it comes to ethical thinking within the nursing profession and delivery of professional health services to patients. Moreover, it will involve nurses’ job satisfaction as well as proper supervision of nursing students. Further research is required in order to explore the concept. To set and maintain a high standard in nurses’ ethical behavior, it will be necessary in the future to ensure optimal ethical leadership on the wards. Furthermore, frequent and regular ethical discussions are important in order to integrate ethical thinking in daily nursing practice. To achieve this, improved ethical knowledge is crucial. In addition, this study showed the importance of a strong and clear leadership, where demands are made to highly professional and ethical practice. A critical and professionally safe culture is necessary to improve ethical thinking. A critical and safe culture is also essential for promoting an evolving culture in which nurses can discuss challenges and responsibilities in their daily work.