Nursing Ethics

Non-violent resistance which has involved healthcare workers has been instrumental in securing a number of health-related gains and a force in opposing threats to health. Despite this, we know little about healthcare workers who have engaged in acts of non-violent resistance.

Amongst a sample of healthcare workers who had engaged in acts of resistance this study sought to explore their understanding of non-violent resistance and how or whether they felt healthcare workers made a distinct contribution to such action.

Cross-sectional survey

Healthcare workers (doctors, nurses, academics and others) from the UK and Europe who had engaged in acts of non-violent resistance.

Ethical approval for this study was granted by the University of Greenwich Human Research Ethics Committee (UREC/20.5.6.11).

Most participants spoke about the nature of non-violent resistance, its oppositional, didactic and symbolic functions and the role of violence or harm. While most people understood non-violent resistance as a public, oppositional and collective act, many identified more subtle everyday acts in the workplace that undermined policy or procedures they saw as harmful. When asked about distinctions in non-violent resistance carried out by healthcare workers, most participants referred to their standing in society, noting that healthcare works were a trusted and authoritative source. Some identified an ethical imperative to act while others identified the risks that came with such action, noting their accountability and responsibility they had to patients. About a quarter of participants felt that such action was no different to others carrying out non-violent resistance or dependent on the issue or nature of the action.

These findings speak to the complex and multifaceted nature of non-violent resistance. Additionally our findings suggest healthcare workers have a distinct role to play in leading and supporting non-violent actions.

Troubled conscience among nurses and other healthcare workers represents a significant contributor to healthcare worker moral distress, burnout and attrition. While research in this area has examined critical care in hospitals, less knowledge has been obtained from long-term care contexts such as nursing homes, despite widely recognised challenges with regard to vulnerable patients, increasing workload and maintaining workforce sustainability among nurses.

The aim of this study was to illuminate and interpret the meaning of the lived experience of troubled conscience among registered nurses (RNs) working in nursing homes.

This qualitative research employed narrative interviews with eight nurses to obtain essential meanings of their lived experiences of troubled conscience. The interview texts were analysed using a phenomenological hermeneutic approach.

Participation was voluntary, informed and was conducted with written consent. The Norwegian Centre for Research Data approved the data processing of personal data.

The analysis uncovered two themes: (1) troubled conscience means abandoning ideals, with the subthemes: failing dependent patients; being disloyal to colleagues; being inadequate in the performance of work tasks and (2) troubled conscience means facing realities, with the subthemes: accepting being part of the system; responding to barriers.

Troubled conscience meant experiencing continuous and simmering tension between one’s ideals and realities and feeling a drive to preserve accountability and one’s moral integrity. Endangered ideals were often under cross-pressure and included humanistic values, professional values, working life values and the values of the organisation.

Nurses’ troubled conscience refers to a struggle, but also a force that plays out at various levels and arenas in long-term care. Openness and dialogue about how professional values and the welfare state’s intentions can be realised within the given framework are important for individual nurses’ occupational health as well as the quality of care provided to patients.

Moral distress, which is especially high in critical care nurses, has significant negative implications for nurses, patients, organizations, and healthcare as a whole.

A moral distress workshop and follow-up activities were implemented in an intensive care unit in order to decrease levels of moral distress and increase nurses’ perceived comfort and confidence in ethical decision-making.

A quality improvement (QI) initiative was conducted using a pre- and post-intervention design. The program consisted of a four-hour interactive workshop, followed by two individual self-reflection activities at 2–3 weeks and 5–6 weeks after the workshop.

Critical care nurses working in a heart and vascular intensive care unit at a large academic medical center.

This study was deemed to be a QI project by the institution’s Institutional Review Board. Participation was voluntary.

Nurses experienced a significant decrease in moral distress. The participants’ average ethical confidence increased in four areas (ability to identify the conflicting values at stake, knowing role expectations, feeling prepared to resolved ethical conflict, and being able to do the right thing), with knowledge of role expectations and feeling prepared to resolve ethical conflict yielding statistically significant increases. Qualitative findings resulted in consistent themes related to causes of moral distress and ways nurses approached addressing moral distress.

This study reinforces previous evidence on moral distress and its causes in critical care nurses, and provides a mechanism for improving moral distress and ethical confidence.

This QI study demonstrates the effectiveness of an evidence-based program for decreasing critical care nurses’ moral distress and increasing their ethical confidence. The strategies described in this paper can replicated by nursing leaders who wish to effect change at their local level, or adapted and expanded to other professions and clinical care units.

Despite its negative impact on patients and nurses, the use of restraint in somatic health care continues in many settings. Understanding the reasons and justifications for the use of restraint among nurses is crucial in order to manage this challenge.

To understand nurses’ justifications for restraint use in neurosurgical care.

A qualitative, descriptive design was used. Data were analysed with inductive qualitative content analysis.

Semi-structured interviews with 15 nurses working in three neurosurgical departments in Sweden.

Approved by The Regional Ethics Committee, Stockholm, Sweden.

The analysis resulted in three categories. The category Patient factors influencing restraint use describes patient factors that trigger restraint, such as a diminished decision-making competence, restlessness, and need for invasive devices. The category Specific reasons for justifying restraint describes reasons for restraining patients, such as restraint being used for the sake of the patient or for the sake of others. The category General reasoning in justifying restraint describes how nurses reason when using restraint, and the decision to use restraint was often based on a consequentialist approach where the nurses’ weighed the pros and cons of different alternatives.

Nurses with experience of restraint use were engaged in a constant process of justifying and balancing different options and actions. Restraint was considered legitimate if the benefit exceeded the suffering, but decisions on which restraint measures to use and when to use them depended on the values of the individual nurse.

How nurses reason when justifying restraint, why they use restraint, and who they use restraint on must be considered when creating programs and guidelines to reduce the use of restraint and to ensure that when it is used it is used carefully, appropriately, and with respect.

Palliative care needs in older persons can endanger their dignity. To provide dignity-conserving care to older persons, the Swedish Dignity Care Intervention (DCI-SWE) can be used. The DCI-SWE is built on Chochinov’s dignity model and the original version, developed and tested in UK and Scotland.

To describe older persons’ and their relatives’ experiences of dignity and dignity-conserving care when using the DCI-SWE in municipal health care.

A mixed method study with convergent parallel design.

The DCI-SWE was used and evaluated in a Swedish municipality health care context. Older persons’ (n=17) dignity-related distress and quality of life were assessed after the intervention. Interviews with older persons (n=10) and their relatives (n=8) were analysed using thematic analysis.

The study followed the World Medical Association Declaration of Helsinki. Ethical approval was obtained from the Regional Ethical Review Board in Uppsala, Sweden (Reg No. 2014/312) and the National Swedish Ethical Review Authority (Reg. No. Ö 10-2019). Informed consent was collected from older persons and their relatives.

The older persons’ dignity-related distress did not significantly change over time (p = 0.44) neither was their overall quality of life (p = .64). Only psychological quality of life was decreased significantly (p = 0.01). The older persons and their relatives emphasized the importance of valuing the individual.

The DCI-SWE provides a forum to talk about dignity issues, but relevant competence, continuity and resources are needed. Psychological care actions and health care professionals’ communication skills training are important. To fully evaluate, the DCI-SWE a larger sample and validated instruments are necessary.

Abortion is one of the most common gynaecological procedures. It is related to personal, social, and economic reasons under a legal term that is recognised as a common sexual and reproductive right in most of countries. However, making the decision to abort is complex, because it is politicised and is often framed in public discourse related to moral or ethical issues beyond women’s experiences. Therefore, it is subject to medical criteria, religious evaluations, and sociological analysis.

The aim of this synthesis of qualitative studies was to synthesise the decision-making experiences of women who legally aborted.

The Noblit and Hare’s interpretive meta‐ethnography was conducted, and it was written in accordance with the eMERGe meta‐ethnography reporting guidance. Ten studies met the research objective and inclusion criteria, after a comprehensive systematic search strategy in five databases.

The metaphor “The wrestling between why and what will happen next” and three themes emerged from the data analysis: (1) Forces that incite the arm wrestling; (2) Facing social stigma; and (3) Defeated by a greater rival. The metaphor provided interpretive experiences of the moral conflict experienced by women who decided to have an abortion and emerged from the confrontation of the reasons why they decided to abort and the social repercussions that making the decision entails. The result of the struggle was loneliness and vulnerability.

The lines of action impact policy makers, the media, and health professionals. Actions should focus on the de-stigmatisation and normalisation of abortion, the use of appropriate language, and the training and sensitisation of health professionals.

Ethical dilemmas that arise in the clinical setting often require the collaboration of multiple disciplines to be resolved. However, medical and nursing curricula do not prioritize communication among disciplines regarding this issue. A common teaching strategy, problem-based learning, could be used to enhance communication among disciplines. Therefore, a university in southern Taiwan developed an interprofessional ethics education program based on problem-based learning strategies. This study described tutors’ experience teaching in this program.

To explore the phenomenon of teaching and learning in interprofessional ethics education for medical and nursing students from the perspectives of tutors.

Phenomenological qualitative research.

Medical and nursing students completed a 6-week interprofessional ethics education program moderated by either physician or nurse tutors. At the conclusion of the ethics education program, all 14 tutors were invited to participate in focus group interviews. Among them, six tutors (three nursing tutors and three physician tutors) participated in additional individual interviews. All of the contents from the focus group interviews and individual interviews were recorded and transcribed. Using the phenomenological approach, the phenomenon of teaching and learning in interprofessional ethics education were generated.

The study was approved by the Institutional Review Board.

Three themes emerged from the tutors' teaching perspectives, including the instructor’s motivation to teach, the use of narrative case scenarios, and the emphasis on improving interprofessional ethics communication.

Problem-based learning creates an interprofessional communication platform in interprofessional ethics education. The phenomenon of value convergence between tutors and students, between different students’ professions, and between different students’ professional maturities is observed.

Problem-based learning is an effective teaching strategy for creating a communication platform for interprofessional ethics education. Ethic curriculum should emphasize motivating instructor, use narrative case scenarios, and focus on interprofessional communication.