Background: Nurses working within acute psychiatric settings often face multifaceted moral dilemmas and incompatible demands. Methods: Qualitative individual and focus group interviews were conducted. Ethical considerations: Approval was received from the Norwegian Social Science Data Services. Ethical Research Guidelines were followed. Participants and research context: Thirty nurses working within acute psychiatric wards in two mental health hospitals. Results: Various coping strategies were used: mentally sorting through their ethical dilemmas or bringing them to the leadership, not ‘bringing problems home’ after work (...) or loyally doing as told and trying to make oneself immune. Colleagues and work climate were important for choice of coping strategies. Discussion: Nurses’ coping strategies may influence both their clinical practice and their private life. Not facing their moral distress seemed to come at a high price. Conclusions: It seems essential for nurses working in acute psychiatric settings to come to terms with distressing events and identify and address the moral issues they face. As moral distress to a great extent is an organisational problem experienced at a personal level, it is important that a work climate is developed that is open for ethical discussions and nourishes adaptive coping strategies and moral resilience. (shrink)

Background In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored. Research design A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used. Ethical considerations Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary. Findings Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral (...) doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness. Conclusion Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves. (shrink)

This article is based on an empirical study regarding ethical challenges in intercultural nursing. The focus is on autonomy and disclosure. Autonomy is a human capacity that has become an important ethical principle in nursing. Although the relationship between autonomy and patients’ possibly harmful choices is discussed, the focus is on ‘forced’ autonomy. Nurses seem to equate respect with autonomy; it seems to be hard to cope with the fact that there are patients who voluntarily undergo treatment but who actively (...) participate neither in the treatment offered nor in making choices regarding that treatment. Nurses’ demand for patients to be autonomous may in some cases jeopardize the respect, integrity and human worth that the ethical principle of autonomy is meant to ensure. Even though respect for a person’s autonomy is also respect for the person, one’s respect for the person in question should not depend on his or her capacity or aptitude to act autonomously. Is autonomy necessarily a universal ethical principle? This article negates this question and, through the issues of culture, individualism versus collectivism, first- and second- order autonomy, communication and the use of family interpreters, and respect, an attempt is made to explain why. (shrink)

Background: In the neonatal intensive care unit, immigrant parents may experience even greater anxiety than other parents, particularly if they and the nurses do not share a common language. Aim: To explore the complex issues of trust and the nurse–mother relationship in neonatal intensive care units when they do not share a common language. Design and methods: This study has a qualitative design. Individual semi-structured in-depth interviews and two focus group interviews were conducted with eight immigrant mothers and eight neonatal (...) intensive care unit nurses, respectively. Data analysis was based on Braun and Clarke’s thematic analytic method. Ethical considerations: Approval was obtained from the hospital’s Scientific Committee and the Data Protection Officer. Interviewees were informed in their native language about confidentiality and they signed an informed consent form. Results: Trust was a focus for mothers and nurses alike. The mothers held that they were satisfied that their infants received the very best care. They seemed to find the nurses’ care and compassion unexpected and said they felt empowered by learning how to care for their infant. The nurses discussed the mother’s vulnerability, dependency on their actions, attitudes and behaviour. Discussion: Lack of a common language created a challenge. Both parties depended on non-verbal communication and eye contact. The nurses found that being compassionate, competent and knowledgeable were important trust-building factors. The mothers were relieved to find that they were welcome, could feel safe and their infants were well cared for. Conclusion: The parents of an infant admitted to the neonatal intensive care unit have no choice but to trust the treatment and care their infant receives. Maternal vulnerability challenges the nurse’s awareness of the asymmetric distribution of power and ability to establish a trusting relationship with the mother. This is particularly important when mother and nurse do not share a verbal language. The nurses worked purposefully to gain trust. (shrink)

Based on an empirical study regarding ethical challenges within intercultural health care, the focus of this article is upon autonomy and disclosure, discussed in light of philosophy and anthropology. What are the consequences for patients if the patients’ right to be autonomous and to participate in treatment and care decisions by health care workers is interpreted as an obligation to participate? To force a person to make independent choices who is socio-culturally unprepared to do so, may violate his/her integrity. This (...) may in turn jeopardise the respect, integrity and human worth the principle of autonomy was meant to ensure, and if so, may damage any relationship of trust that may exist between patient and health care worker. There is necessarily a link between autonomy and disclosure. Western disclosure practices may make the relationship between patients and health care workers difficult -- even distrustful. To confront a patient with a very serious diagnosis may be seen not only as a tactless action, but also an unforgivable one. Hence, among many ethnic groups it is a family member’s duty to shield patients from bad or disquieting news, e.g., a cancer diagnosis. If a family member is used to interpret in such situations, will the information given equal the information communicated by that interpreter? Even though respect for a person’s autonomy is part of the respect for a person, one’s respect for the person in question should not depend on his/her ability or aptitude to act autonomously. (shrink)

Background Non-technical skills are cognitive and interpersonal skills underpinning technical proficiency. Ethical values and respect for human dignity make operating room nurses responsible for nursing decisions that are clinically and technically sound and morally appropriate. Aim To learn what ethical issues operating room nurses perceive as important regarding non-technical skills. Research design Qualitative individual in-depth interviews were conducted. The interviews were analysed using Braun and Clarke’s six phases for thematic analysis. Participants and research context Eleven experienced perioperative/operating room nurses working (...) in an operating unit at a Norwegian university hospital. Ethical considerations Approval was given by The Norwegian Social Science Data Service in care of the hospital’s Data Protection Officer. Findings Three main themes were found: respect and care for the patient, making the patient feel safe, and respect within the perioperative team. These features or themes, which incorporate collaboration and communication, are closely connected to patient safety. Discussion Defending the patient’s dignity is part of caring for and respecting the patient. The manner in which the operating room team collaborates is important for the patient to feel safe and secure. Poor teamwork may have dire consequences. Reciprocal respect within the team includes respect for each other’s tasks and responsibilities and to talk to one another in a friendly manner. Conclusion Being respectful and contributing to a caring atmosphere are central ethical skills in the operating room. To patients, harmonious teamwork translates into a feeling of safety and being cared for. The nurses see respect and patient safety, and respect and reciprocal politeness among the members of the perioperative team as central ethical non-technical skills. Lack of respect influences the team negatively and is detrimental for patient safety. Good communication is an important safety measure during surgery and creates a feeling of good ‘flow’ within the operating room team. (shrink)

Background: If collectivistic-oriented family carers choose professional care for dependents with dementia, they risk being stigmatised as failing their obligation. This may influence dementia care choices. Research question: How may individualistic and collectivistic values influence choices in dementia care? Method: Qualitative design with in-depth interviews with a total of 29 nurses, 13 family members in Norway and the Balkans and 3 Norwegian dementia care coordinators. A hermeneutic content-focused analysis was used. Ethical considerations: Ethical approval was obtained from the Regional Ethics (...) Committee for Research, South-Eastern Norway, and the nursing homes’ leadership. Findings: Family domain reasons why institutionalisation of dependents with dementia was seen as a last resort: obligation towards family members, particularly parents; worry about other family members’ reactions and inability to cope with the care for the person with dementia. Social domain reasons: feelings of shame and stigma regarding dementia, particularly in connection with institutionalisation of family members. Discussion: Children’s obligation towards their parents is an important aspect of the morality of collectivistic societies. Institutionalising parents with dementia may cause feelings of guilt and shame and worry about being stigmatised and ostracised. To avoid blame and rejection, caregiver(s) try to keep the fact that family members have dementia ‘in the family’. The decision to accept professional healthcare for dependents with severe dementia or have them admitted to a geriatric institution was postponed as long as possible. Conclusion: Family care morality may constitute a significant barrier against seeking professional help for persons with dementia, a barrier based on the expectation that the family will care for their old, even when suffering from severe dementia. Hence, stigma and shame may significantly affect the provision of care. Culturally tailored information may encourage family carers to seek professional help before the disruptive influence of the disease makes institutionalisation the only feasible option. (shrink)

Background: To place a dependent with severe dementia in a nursing home is a painful and difficult decision to make. In collectivistic oriented societies or families, children tend to be socialised to care for ageing parents and to experience guilt and shame if they violate this principle. Leaving the care to professional caregivers does not conform with the cultural expectations of many ethnic groups and becomes a sign of the family’s moral failure. Research design: Qualitative design with individual in-depth interviews (...) with nurses, family members and dementia care coordinators in Norway, Montenegro, Serbia and South Africa. Braun and Clarke’s six analytic phases were used. Ethical considerations: The project was approved by the Regional Committee for Research, South-Eastern Norway; the Norwegian Centre for Research Data; the Ethics Committee; University of Limpopo, MEDUNSA Campus, South Africa; and by the local heads of the respective nursing homes or home care services. Interviewees were informed orally and in writing and signed an informed consent form. Findings: Healthcare professionals tend to be contacted only when the situation becomes unmanageable. Interviewees talked about feelings of obligation, shame and stigma in their societies regarding dementia, particularly in connection with institutionalisation of family members. Many lacked support during the decision-making process and were in a squeeze between their own needs and the patients’ need of professional care, and the feeling of duty and worry about being stigmatised by their surroundings. This conflict may be a source of pre-decision regret. Conclusion: Family caregivers need help to understand the behaviours of persons with dementia and how to access the formal and informal services available. Thus, they may provide effective support to patients and family carers alike. Supportive interventions for caregivers need to be tailored to meet the individual needs of both the caregiver and the persons with dementia. (shrink)

Two areas of ethical conflict in intercultural nursing — who needs single rooms more, and how far should nurses go to comply with ethnic minority patients’ wishes? — are discussed from a utilitarian and common-sense morality point of view. These theories may mirror nurses’ way of thinking better than principled ethics, and both philosophies play a significant role in shaping nurses’ decision making. Questions concerning room allocation, noisy behaviour, and demands that nurses are unprepared or unequipped for may be hard (...) to cope with owing to physical restrictions and other patients’ needs. Unsolvable problems may cause stress and a bad conscience as no solution is ‘right’ for all the patients concerned. Nurses experience a moral state of disequilibrium, which occurs when they feel responsible for the outcomes of their actions in situations that have no clear-cut solution. (shrink)