Critical care nurses’ moral sensitivity during cardiopulmonary resuscitation: Qualitative perspectives

Introduction

During their day-to-day work, nurses are constantly faced with contradictory situations imbued with moral issues that challenge their knowledge and skills, ¹ and for this reason, they may have difficulty understanding the moral dimensions of the developed situations. In such circumstances, it is moral sensitivity as an ability that enables nurses to fully recognize the moral challenges of the subject and gain a good understanding of their work situation. ² In the nursing profession, moral sensitivity is defined as the nurse’s ability to identify the moral components of a particular conflict and make moral decisions based on personal and contextual values. ³ One of the areas full of complex moral issues is Cardiopulmonary Resuscitation (CPR), which is a procedure during which the patient is unconscious and has no will to impose. The manner of dealing with these patients and deciding about therapeutic actions for them has always been an issue for nurses and has created many moral challenges that sometimes make decision-making quite difficult. ⁴ For instance, moral principles such as “autonomy” and “patient independence,” which are among the most important considerations in bioethics, have recently been acknowledged as a right that is even more important than the right to live in certain scenarios, such as in CPR. ⁵ Meanwhile, the moral performance of nurses in CPR in congruence with these principles may vary from one community to another depending on the cultural and social context. For instance, in Muslim countries, the Do Not Resuscitate (DNR) order is not carried out even if the patients and their families so wish, because such act contradicts the Islamic values, as the teachings of Islam consider even the last seconds of human life very valuable.^6-8 In addition, factors such as race and ethnicity, spiritual beliefs, personal characteristics, and educational issues can also affect nurses’ attitude toward CPR and its corresponding moral issues. ⁹ In this communities, nurses’ emphasis on performing CPR or DNR, not only affects the relationship they establish with the patients and their families and overshadows the required arrangements for the implementation of the care program, but it also leads to negligence of the values and preferences of the patients and their families and creates further moral challenges. ¹⁰ Moreover, based on the points discussed, although nurses still observe common ethical principles with medicine, they seek to separate their professional ethics from it.^11-13 Therefore, it is necessary to reconsider the concepts of bioethics principles in CPR, to place related moral issues within a framework, and develop reliable theories for nurses in this area. ¹⁴ The question arises as to what the elements and components of nurses’ moral sensitivity in CPR are, and whether these components differ from the dimensions of moral sensitivity in conscious patients. Identifying and understanding such elements can help create measures to promote care methods based on morality and create and develop moral sensitivity in health centers, especially in Iran and culturally similar countries. The resulting knowledge can also help promote the moral awareness and moral performance of nurses. Despite the importance of nurses’ moral sensitivity toward unconscious patients and CPR, very few studies have been conducted on this subject, and even they have not examined the various dimensions of this concept and the components of nurses’ moral sensitivity in this area are yet to be determined. On the one hand, due to the lack of exclusive and reliable nursing theories on this subject and the inadequacy of the fixed principles of bioethics and laws as a model for the daily moral performance of nurses, we cannot answer all the moral issues and problems in this area. On the other hand, considering the different cultures and religious beliefs, the components of moral sensitivity in CPR for unconscious patients can be different from one society to another. Therefore, it is pivotal to identify these components and the moral issues to which nurses are sensitive and respond in CPR. Cardiopulmonary resuscitation requires immediate and rapid decisions, which means that nurses should follow very clear and humane decision-making processes based on moral sensitivity skills, and the possession of moral sensitivity can be determining in this scenario. Therefore, this study was conducted to fill the existing gap and explore and identify the components of moral sensitivity in critical care nurses with respect to CPR.

Materials and Methods

Findings

The data analysis resulted in the extraction of four main themes and 12 sub-themes, which are presented in Table 1.

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Table 1.

Themes, sub-themes, and codes.

Themes	Sub-themes	Codes
Consciously and compassionate attention to resuscitate the patient	Moral responsibility	Accurate and proper administration of drugs
		Implementing care measures as quickly as possible and in the most accurate way
		Providing care based on the right principles
		Performing tasks without the need for supervision
	Sacrifice and forgiveness	Helping patients regardless of one’s job duties
		Working beyond one’s duties
		Prioritizing the patients’ interests
		Quick start of CPR despite not having enough authority
	Awareness of the confidentiality dimension of CPR	Keeping the patients’ secrets confidential and not disclosing them to others
		Not inquiring about the patients’ problems
		Respecting the privacy of the patients during defecation
		Keeping the dead body clean and tidy at the end of CPR
		Protecting the patients’ clothing during and after CPR
	Making best efforts to resuscitate the patients	Not allowing superficial issues to affect the efforts to resuscitate the patient
		Making every effort to resuscitate the patient
		Trying to succeed at resuscitation beyond the legal timeframe
		Doing anything a nurse can do
Awareness of families’ anxiety	Understanding and informing the waiting families	Understanding the concerns of the patients’ families while waiting and paying attention to their presence
		Providing informational support to the patients’ families during CPR
		Creating a waiting space for the patients’ families
	Need for preparing the families’ encounter in a reassuring atmosphere	Reassuring the patients’ families about the CPR team’s efforts
		Preparing the patients’ families for their gradual exposure
	Attention to psychologically relieve pain	Offering consultation to the patients’ families during CPR
		Sympathizing with the patients’ families
		Allowing controlled mourning
Understanding the teamwork and interactive guidance of the CPR process	Attention to behaviors and interactions	Paying attention to the conversations between the CPR team members
		Paying attention to how the patients’ families are treated
		Paying attention to conversations during CPR
		Avoiding jokes and laughter during CPR
	Attempts to control the traffic	Controlling the human traffic in the CPR room
		Controlling entry and exit to the CPR room
		Not overcrowding the patient’s bedside
	Understanding the teamwork nature of CPR	The teamwork nature of CPR and nurses as a member of the team
		The need for the CPR team to be led and managed by one person
Compulsory violation of moral principles	Violation of the principle of autonomy	Negligence of the patients’ preferences
		Negligence of the preferences of the patients’ families
	Violation of the principle of nonmaleficence	CPR having no benefit for some patients
		Compulsory CPR of end-stage patients according to the law
		The lack of indication or benefit for some patients
		Violent CPR of end-stage patients not being moral
		Causing more complications for end-stage patients by CPR
		Bothering end-stage patients by imposing CPR on them

Theme 1. Consciously and compassionate attention to resuscitate the patient

One of the themes of the present study was “Consciously and compassionate attention to resuscitate the patient,” which had the following four sub-themes: moral responsibility, sacrifice and forgiveness, awareness of the confidentiality dimension of CPR, and making best efforts to resuscitate the patients.

Moral responsibility: Accepting responsibility for patients under CPR was one of the components of moral sensitivity. Nurses considered themselves responsible for performing their duties accurately and correctly without anyone else’s supervision. One of the nurses said:

“When Code Blue is announced, I rush to the patient’s bedside as soon as possible and find a vein for the IV immediately. I try to do my job properly and don’t wonder to myself whether anyone is supervising me or not. There is no need for anyone to monitor and inspect me there; I have to do what I’ve accepted to do” (P4, female, 37y)

Sacrifice and forgiveness: Another thing that most participants agreed upon was Sacrifice. They sacrificed their personal interests for the sake of the patient’s health and considered it a moral attribute of theirs. One of them said:

“I go to the patient’s bedside before the physician arrives and do everything I can to save them. Sometimes the physician reproaches me that I have acted outside the scope of my authority, but I tolerate these matters and try to give priority to the patient’s interest as much as I can” (P2, female, 45y)

Awareness of the confidentiality dimension of CPR: Most nurses considered the protection of the patients’ secrets and their non-disclosure an important moral component and one of the basic human rights of the patients. One nurse noted:

“The nurse must keep the problems of the patients and their families confidential. She should not inquire about their problems and not spread the patients’ secrets from one ward to another. The families and patients are entitled to the non-disclosure of their secrets and nurses are morally obliged to observe this right. I personally respect these rights” (P5, male, 34y)

Also despite the urgency of the situation, nurses considered themselves morally committed to respecting the privacy of the patients. One of the participants suggested:

“One thing I’m sensitive about is the patients’ privacy. In any case, both men and women should have their privacy respected. No one may have seen or touched their body that easily through their whole life, and now that they are sick and have no will, we should not treat their body just any way we like” (P8, female, 50y)

Making best efforts to resuscitate the patients: Another component to which the nurses were morally sensitive was making their best efforts to save the patients’ life. One nurse described their experiences as follows:

“I do whatever I can during CPR, whether it’s my duty or not; at that moment, I don’t wonder whether it’s my job or not. I do my best to advance any part of the work that helps with the patients’ condition and accelerates their recovery” (P7, female, 49y)

Theme 2. Awareness of families’ anxiety

Paying attention to the patients’ families and their problems during the CPR process was of great inner moral value to the nurses. This theme had three sub-themes: Understanding and informing the waiting families, need for preparing the families’ encounter in a reassuring atmosphere, and attention to psychologically relieve pain.

Understanding and informing the waiting families: One of the components of nurses’ moral sensitivity toward the families of patients under CPR was understanding their concerns and giving them information. The nurses talked about effective communication and informing the patients’ families about the CPR process. One of them said:

“An example of a moral issue that I am sensitive to during CPR is paying attention to the patient’s family and company and understanding their situation. We would give the opportunity and space to the patient’s family to wait there during the CPR, and a connection would be established inside and outside the CPR room so that the patient’s family could be informed about the treatment process” (P2, female,45y)

Need for preparing the families’ encounter in a reassuring atmosphere: The nurses considered themselves morally responsible to prepare the patients’ families for their encounter with the CPR outcomes in advance, and in their view, paying attention to this issue indicated the possession of moral sensitivity in the nurse. One of the nurses stated:

“By explaining the CPR process to the patients’ families, we prepare them for accepting the CPR outcomes, so that we can both calm down the families and reassure them that the CPR team will do their best, and also prepare them to face the situation and not get shocked by any news. It is not moral to come out of the CPR room and flat out tell them ‘Your patient died” (P13, female, 38y)

Attention to psychologically relieve pain: Although the emergency of CPR could prevent nurses from paying attention to the patients’ families, the nurses stated that despite the critical nature of the situation, they sympathized with the patients’ families and paid attention to their psychological state. One of the nurses said:

“With the loss of a loved one, they become a restless and agitated family. In this situation, we allow them to mourn, sympathize with them and give them advice. Yes, they may get aggressive and blame the nurses, but in such cases, you should not argue with them; you should put yourself in their shoes” (P19, female, 35y)

Theme 3. Understanding the teamwork and interactive guidance of the CPR process

Due to the teamwork nature of CPR and the growing need for appropriate interactions between the team members, nurses showed moral sensitivity to this issue when recounting their experiences. This theme had three sub-themes: Attention to behaviors and interactions, attempts to control the traffic, and understanding the teamwork nature of CPR.

Attention to behaviors and interactions: In a self-motivated way, the nurses paid attention to the interactions, conversations, and behaviors of themselves and the other team members during CPR to improve the CPR team’s performance. One of them said:

“I always pay attention to what I say first and then to what the CPR team says. I have seen some people joking around and laughing during CPR; maybe it is normal for them, but these behaviors are not morally correct and we should be sensitive” (P3, female, 51y)

Attempts to control the traffic: The nurses viewed controlling entry and exit to the CPR room and managing the situation as their moral responsibility and discussed it when recounting their experiences. One nurse stated:

“During CPR, especially in teaching hospitals, sometimes there’re a lot of people coming and going. Anyway, the students come and go, and teaching them is one story, but also there’re a lot of staff from non-nursing units, such as physicians, service personnel, etc. In this situation, I morally try to minimize the traffic so that the patients’ privacy is not compromised” (P12, female, 48y)

Understanding the teamwork nature of CPR: Although nurses, physicians, and other medical professionals work separately, in team activities such as CPR, nurses understand the importance of teamwork and consider themselves part of the team. One of the participants said:

“I’m careful during CPR so that my comments do not cause disorder, because CPR is a team effort and should be led by only one person. That is, not everyone should give an opinion; for example, it shouldn’t be like this that the nurse gives one opinion, the physician gives another, and the supervisor yet another. This can harm the patient and is not morally right” (P11, male, 54y)

Theme 4. Compulsory violation of moral principles

Another moral component faced by nurses in CPR was the compulsory violation of moral principles. Especially with the impossibility of following a DNR order in Iran, this component was a serious moral concern for the nurses. The sub-themes of this theme included: Violation of the principle of autonomy, violation of the principle of nonmaleficence, and violation of the principle of beneficence.

Violation of the principle of autonomy: In the nurses’ experience, CPR is one of the conditions in which the patients’ autonomy is violated and this leads to medical paternalism. The experience of one of the nurses was as follows:

“Patients under CPR are unconscious and have no will to say what they prefer. While morally, we should work in a patient-centered way, physicians do not take that responsibility. I once raised the issue with a physician who said that patients cannot participate in the treatment and recognize the best option in all circumstances, and an expert should comment on what is appropriate” (P1, male, 36y)

Violation of the principle of nonmaleficence: The nurses suggested that making decisions about CPR and its duration often requires the consideration of several important moral issues that are sometimes beyond their control. They considered performing violent CPR on end-stage patients an example of violating the moral principle of nonmaleficence. One of the nurses said:

“It has always been one of my work challenges and concerns that sometimes we are given end-stage patients and we know that nothing can be done to save them, but unfortunately, this is not culturally accepted in our country that a patient who is in the last stage of his life should not be bothered or receive violent CPR. From an ethical point of view, no violent CPR should be performed for these patients, and we shouldn’t be bothering the patient and harming their body and soul by doing CPR” (P6, male, 12y)

Discussion

This study, which was conducted on nurses’ experiences of the components of moral sensitivity in CPR, found four themes, namely, “Consciously and compassionate attention to resuscitate the patient,” “Awareness of families’ anxiety,” “Understanding the teamwork and interactive guidance of the CPR process,” and “Compulsory violation of moral principles.” One of the components that were abstracted from the nurses’ experiences was “Consciously and compassionate attention to resuscitate the patient,” which itself had the subcomponents of moral responsibility, sacrifice and forgiveness, awareness of the confidentiality dimension of CPR, and making best efforts to resuscitate the patient. In this study, nurses described conscientiousness and the principled and accurate performance of duties as examples of being moral responsibility. Similarly, in a study conducting interviews with nurses, accountability was conceptualized as “responsive use of self.” ¹⁹ Clancy et al. also proposed responsibility as a subset of moral terms and components. ²⁰ Lutzen et al. ²¹ found moral sensitivity to include more dimensions such as moral responsibility. In line with the present findings, the legitimacy of the current dimensions of moral sensitivity was found questionable in terms of application of moral authority to different contexts of health care. Sacrifice and forgiveness was another subcomponent noted by the nurses. Regardless of their job descriptions and professional authority, they prioritized saving the patients’ life, and according to their statements, although they were sometimes criticized, they still forgave and sacrificed themselves. This item depicts the highest level of moral sensitivity in nurses in the context of CPR. Similar studies have also discussed self-sacrifice as one of the moral values of nurses.^{22, 23} Awareness of the confidentiality dimension of CPR was another subcomponent of this theme. Confidentiality is a recognized value and one of the moral codes in nursing. ²⁴ Most nurses agreed that respect for the patients’ privacy and clothing is a prerequisite of moral sensitivity in nurses. For instance, they stated that even when a female nurse is sending a shock to a female patient, their clothes should be removed with great respect. Although this item is not a new finding, nurses’ moral sensitivity to this issue may indicate their concern for patients’ human rights even in the later stages of life. In many similar studies, nurses have emphasized the importance of paying attention to the patients’ privacy from the point of view of moral compliance.^25-27 Making best efforts to resuscitate the patient regardless of trivial issues was another subcomponent of moral sensitivity in this study. That is, the nurses did everything they could to resuscitate the patients regardless of their condition. Similarly, Park et al. stated that nurses do not make any adjustments in their care activities for dying patients, continue to do their best for them, and do not lessen their therapeutic efforts ²⁸ In line with the present research, a study by Cingel (2011) defined sympathy with patients as the care provided by nurses using their best efforts. Consciously and compassionately paying attention to patients can therefore constitute a key dimension of moral sensitivity in nurses during CPR ²⁹ .

Awareness of families’ anxiety was another component of nurses’ moral sensitivity in CPR. Understanding and informing the waiting families, need for preparing the families’ encounter in a reassuring atmosphere, and attention to psychologically relieve pain were its subcomponents. According to the nurses, although CPR is an emergency and a critical situation, there is no reason to morally neglect the patients’ families. They proposed understanding the concerns of the patients’ families while waiting for the outcome of the work and providing informational support to them as examples of moral sensitivity. According to the nurses, keeping the patients’ families informed about the process of CPR for their patient not only helps them better understand the current situation and prevents aggressive reactions, but also prepares them for facing and accepting the CPR outcomes. Consistently, Park et al. stated that nurses should explain the condition of dying patients to their families and inform them in advance of possible outcomes . ²⁸

Another finding of this study is “understanding the teamwork and the interactive guidance of the CPR process”, which has the following components: Attention to behavior and interactions, attempts to control human traffic, and understanding the teamwork nature of CPR. Cardiopulmonary resuscitation is one of the procedures in which several professions work together. Even though nurses constantly seek professional independence, they understood the importance of teamwork and tried to follow the principles of teamwork, such as following the team leader. Although they had not received specific training on team performance in CPR based on personal experience, they considered adhering to the principles of teamwork a significant moral component in the patient’s best interest. Furthermore, nurses believed that establishing the right professional relations based on interaction with the patient, the patient’s family, and other team members during the resuscitation process is not separated from morality and in fact considered it an essential element of moral sensitivity. In another study, Carlisle found that experienced nurses focus on the overall outcome of teamwork and what the team does, while in contrast, inexperienced individuals focus on what they themselves do. ³⁰ Similarly, the importance of the nurse’s experience in understanding the teamwork nature of CPR is evident from the present study, which was conducted by interviewing experienced nurses.

Another condition that aroused the moral sensitivity of nurses was the compulsory violation of moral principles. Although the four principles of bioethics are recognized as moral language and common framework throughout the world, they are not sufficient in all clinical settings and situations, yet they are still widely used and discussed, despite their limitations. ³¹ It should be noted that the possibility or impossibility of the “Do Not Resuscitate” order varies from one country to another. For instance, in Iran, it is impossible to have a DNR order in place in the law and all patients must therefore be resuscitated under any circumstances. In such a context, where there are many ambiguities in the laws, nurses become confused and face a compulsory violation of moral principles. One of these principles is the principle of the patient’s autonomy. In this study, nurses were confronted with cases in which the request to not resuscitate was ignored despite the patient’s or family’s preferences, which is contrary to the moral principle of respect for autonomy. Nevertheless, it should be noted that the nurses, only mentioned cases in which they already knew the patient and were aware of the patient’s and their family’s wishes, but there are more cases of compulsory violation of the patient’s autonomy. For instance, in cases where the nurse is not yet familiar with a patient because he has just entered the emergency ward, CPR may be inconsistent with the patient’s desire to not be resuscitated although the nurse still does not know about this preference. According to the participants, in such situations, it is the physician who decides on the death and life of the patients, and this decision-making power can lead to medical paternalism. Meanwhile, in countries where DNR is accepted as a law, this order is considered desirable because it shows respect for the principle of autonomy, although it might be painful . ²⁸ The preferences of unconscious patients might be ignored by their family, nurses and physicians during CPR. Given “respect for patient autonomy” as a dimension of moral sensitivity, observing patient autonomy and the role played by nurses are crucial in CPR. According to Tı´scar-Gonza´lez et al. ³² , nurses fail to perfectly play their role in CPR by participating in a kind of pact of silence and ignoring patient preferences. According to Mohammed and Peter, although CPR is often considered futile as per current medical standards, it is of a significant ceremonial value and social function and involves nurses with complex moral responsibilities. ³³ Irrespective of having a DNR rule in place, a new perspective in CPR should be considered on autonomy as a dimension of moral sensitivity given the numerous consequences of the failure of nurses to effectively play their role. Another moral principle that was forcibly violated was the principle of nonmaleficence. The nurses faced elderly and end-stage patients in whom the CPR outcome was evident in advance, yet they had to perform violent CPR on them. In such a scenario, the patient’s body and soul are hurt and the patient suffers. Also, the principle of beneficence was violated for these patients, because performing CPR on such patients was useless, and not only did the patient not benefit from it, but they also suffered through the procedure. A similar study stated that prolonging the death process is sometimes not in the best interest of the patients and contradicts the moral principle of nonmaleficence. ³⁴

Investigating “experiencing moral conflict,” “following the rules,” “relational orientation,” “expressing benevolence,” “modifying autonomy,” and “structuring moral meaning” as the dimensions of moral sensitivity in conscious patients and comparing them with the components of moral sensitivity in CPR showed differences, for example, in “awareness of family anxiety” as a new dimension, which can be explained by a wide range of dimensions of moral sensitivity in unconscious compared to in conscious patients. Cultural background can also contribute to this effect. It is recommended that further studies be conducted to thoroughly identify the dimensions of moral sensitivity in unconscious patients such as those undergoing CPR, modify the existing laws in different communities and ensure that ethical nursing care is provided for patients and families. According to Liaschenko and Peter, ³⁵ the ethical challenges of care can be no longer overcome based on the current understanding of ethics associated with nursing as a profession and practice. In fact, nursing can gain the identity of independent professional ethics through striving in all areas rather allowing moral dos and don’ts to be dictated.

Conclusion

Cardiopulmonary resuscitation is one of the most morally sensitive situations with which critical care nurses are faced on a daily basis. Based on the findings of this study, this context necessarily requires nurses’ high moral sensitivity so that they both focus on providing moral care to the patients and simultaneously avoid neglecting the patient’s family and continue reassuring them. Also, by understanding their role in the CPR team, nurses should pay attention to teamwork and the interactive guidance of the CPR process. Nevertheless, there are sometimes situations in which moral principles are inevitably violated, which are mostly related to the laws and regulations and are beyond the control of nurses. Such conditions can have consequences for nurses, patients, and health centers. Consequently, more clarification is needed on certain aspects of complex and ambiguous moral and legal issues such as DNR, as well as on what constitutes an acceptable level of quality of life and the struggle to maintain it, the provision or non-provision of special care, and the cost-benefit issue, especially considering the high costs of care. Therefore, exploring and identifying the components of nurses’ moral sensitivity in the context of CPR can, in the absence of independent and reliable nursing theories in this field, develop nurses’ moral sensitivity toward unconscious patients to a large extent, especially patients receiving CPR, and assist them in making moral decisions in this context. Understanding these components also helps nursing managers identify situations in CPR that require nurses’ moral sensitivity so as to support nurses in such situations.