"It Kills Your Soul": A Mixed Methods Study of Ethical Sensitivity of Critical Care Nurses.

BACKGROUND: Critically ill patients often experience distressful and impactful symptoms and conditions that include pain, agitation/sedation, delirium, immobility, and sleep disturbances (PADIS). The presence of PADIS can affect recovery and long-term patient outcomes. An integral part of critical care nursing is PADIS prevention, assessment, and management. Ethical sensitivity of everyday nursing practice related to PADIS is an imperative part of implementing evidence-based care for patients. OBJECTIVE: The first 2 aims of this study were to determine the measured level of ethical awareness as an attribute of ethical sensitivity among the critical care nurse participants and to explore the ethical sensitivity of critical care nurses related to the implementation of PADIS care. The third aim was to examine how the measured level of ethical awareness and ethical sensitivity exploration results converge, diverge, and/or relate to each other to produce a more complete understanding of PADIS ethical sensitivity by critical care nurses. METHODS: This was a convergent parallel mixed methods study (QUAL + quant). Ethical sensitivity was explored by conducting an ethnography of critical care nurses. The participants were 19 critical care nurses who were observed during patient care, interviewed individually, participated in a focus group (QUAL), and were administered the Ethical Awareness Scale (quant). FINDINGS: Despite high levels of individual ethical awareness among nurses, themes of ambiguous beneficence, heedless autonomy, and moral distress were found to be related to PADIS care. CONCLUSIONS: More effort is needed to establish moral community, ethical leadership, and individual ethical guidance for nurses to establish patient-centered decision-making and PADIS care.

Do-not-resuscitate order in COVID-19 times: bioethics and professional ethics.

OBJECTIVE: To reflect about the do-not-resuscitation order at COVID-19 in Brazil, under bioethical focus and medical and nursing professional ethics. METHOD: Reflection study based on the principlist bioethics of Beauchamps and Childress and in professional ethics, problematizing actions, and decisions of non-resuscitation in the pandemic. RESULTS: It is important to consider the patient's clinic, appropriation of treatment goals for people with comorbidities, elderly people, with less chance of surviving to resuscitation, or less quality of life, with the palliative care team, to avoid dysthanasia, use of scarce resources and greater exposure of professionals to contamination. CONCLUSION: COVID-19 increased the vulnerabilities of professionals and patients, impacting professional decisions and conduct more widely than important values ​​such as the restriction of freedom. It propelled the population in general to rethink ethical and bioethical values ​​regarding life and death, interfering in decisions about them, supported by human dignity.

Factors affecting nursing error communication in intensive care units: A qualitative study.

BACKGROUND: Error communication includes both reporting errors to superiors and disclosing their consequences to patients and their families. It significantly contributes to error prevention and safety improvement. Yet, some errors in intensive care units are not communicated. OBJECTIVES: The aim of the present study was to explore factors affecting error communication in intensive care units. DESIGN AND PARTICIPANTS: This qualitative study was conducted in 2019. Participants were 17 critical care nurses purposively recruited from the intensive care units of 2 public hospitals affiliated to Iran University of Medical Sciences, Tehran, Iran. Data were collected through in-depth semi-structured interviews and were analyzed through the conventional content analysis method proposed by Graneheim and Lundman. ETHICAL CONSIDERATIONS: The Ethics Committee of Iran University of Medical Sciences, Tehran, Iran approved the study (code: IR.IUMS. REC.1397.792). Participants were informed about the study aim and methods and were ensured of data confidentiality. They were free to withdraw from the study at will. Written informed consent was obtained from all of them. FINDINGS: Factors affecting error communication in intensive care units fell into four main categories, namely the culture of error communication (subcategories were error communication organizational atmosphere, clarity of processes and guidelines, managerial support for nurses, and learning organization), the consequences of errors for nurses and nursing (subcategories were fear over being stigmatized as incompetent, fear over punishment, and fear over negative judgments about nursing), the consequences of errors for patients (subcategories were monitoring the effects of errors on patients and predicting the effects of errors on patients), and ethical and professional characteristics (subcategories were ethical characteristics and inter-professional relationships). DISCUSSION: The results of this study show many factors affect error communication, some facilitate and some prohibit it. Organizational factors such as the culture of error communication and the consequences of error communication for the nurse and the patient, as well as individual and professional characteristics, including ethical characteristics and interprofessional relationship, influence this process. CONCLUSION: Errors confront nurses with ethical challenges and make them assess error consequences and then, communicate or hide them based on the results of their assessments. Health authorities can promote nurses' error communication through creating a supportive environment for them, developing clear error communication processes and guidelines, and providing them with education about the principles of ethical practice.

Assessment of the Relationship between Nurses' Perception of Ethical Climate and Job Burnout in Intensive Care Units.

OBJECTIVES: To determine the relationship between ethical climate and burnout in nurses working in Intensive Care Units (ICUs). METHODS: This cross-sectional and multi-center study was conducted among 212 nurses working in adult ICUs of six hospitals affiliated to Shiraz University of Medical Sciences, Iran in 2019. The participants were selected using systematic random sampling technique. Data was collected using valid instruments of Olson's Hospital Ethical Climate Survey (HECS) and Maslach Burnout Inventory (MBI). RESULTS: Ethical climate was favorable (3.5±0.6). The intensity (32.2±12.4) and frequency (25.5±12.4) of burnout were high. Ethical climate had significant and inverse relationships with frequency of burnout (r =-0.23, p=0.001) and with intensity of burnout (r=-0.186, p=0.007). Ethical climate explained 5.9% of burnout. Statistically significant relationships were also found between these factors: age with ethical climate (p=0.001), work shifts with burnout (p=0.02), and gender and with intensity frequency of burnout in ICU nurses (p=0.038). The results of Spearman correlation coefficient showed significant and inverse relationships between ethical climate and job burnout (r=-0.243, p < 0.001). CONCLUSIONS: Nurses in ICUs perceived that ethical climate was favorable however, burnout was high. Therefore, burnout can be affected by many factors and it is necessary to support ICU nurses since they undertake difficult and complicated task. It is recommended to assess factors that increase burnout and adopt specific measures and approaches to relieve nursing burnout.

Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community.

Burnout incurs significant costs to health care organizations and professionals. Mattering, moral distress, and secondary traumatic stress are personal experiences linked to burnout and are byproducts of the organizations in which we work. This article conceptualizes health care organizations as moral communities-groups of people united by a common moral purpose to promote the well-being of others. We argue that health care organizations have a fundamental obligation to mitigate and prevent the costs of caring (eg, moral distress, secondary traumatic stress) and to foster a sense of mattering. Well-functioning moral communities have strong support systems, inclusivity, fairness, open communication, and collaboration and are able to protect their members. In this article, we address mattering, moral distress, and secondary traumatic stress as they relate to burnout. We conclude that leaders of moral communities are responsible for implementing systemic changes that foster mattering among its members and attend to the problems that cause moral distress and burnout.

Ethical Concerns Caring for the Stroke Patient.

Stroke is a sudden, unexpected illness with an uncertain prognosis for functional recovery. Ethical issues in the care of patients with stroke include assessment of decision-making capacity when cognition or communication is impaired, prognostication, evaluation of quality of life, withdrawal or withholding of life-sustaining treatment, and how to optimize surrogate decision making. Skilled communication between clinicians and patients or their surrogates promotes shared decision making and may prevent ethical conflict. Nurses with an understanding of the ethics of stroke care play an important role in the care of patients with stroke and their families.

Moral Distress: Defined and Described by Neonatal and Pediatric Critical Care Nurses in a Quaternary Care Free-Standing Pediatric Hospital.

BACKGROUND/INTRODUCTION: Despite a growing population of chronically and acute critically ill neonatal and pediatric patients, there were few published articles related to moral distress as experienced by nurses caring for these patients. OBJECTIVES/AIMS: The aim of this study was to define moral distress based on the perceptions and experiences of neonatal and pediatric critical care nurses. METHODS: A qualitative descriptive study using focus group methodology was undertaken. All nurses with 2 or more years of experience from the 4 neonatal and pediatric intensive care units in a large 404-bed urban pediatric hospital located in the northeast were invited to attend 1 of 15 audio-recorded focus groups lasting 60 to 90 minutes. Once data were transcribed, conventional content analysis was used to develop the definition and categories of moral distress. RESULTS: Nurse participants defined moral distress as "patient care situations where there is a mismatch or incongruity between expected behaviors of the nurse and his/her personal values/beliefs in the neonatal/pediatric critical care setting." The 2 overarching categories that emerged from the data were patient-focused factors and nurse-focused factors. DISCUSSION/CONCLUSIONS: Understanding how neonatal and pediatric critical care nurses define moral distress and what contributes to its development is foundational to developing targeted strategies for nursing support and education, with the goal of creating a culture of moral resiliency.

Ethical conflicts and their characteristics among critical care nurses.

INTRODUCTION: Ethical conflict is a phenomenon that has been under study over the last three decades, especially the types moral dilemma and moral distress in the field of nursing care. However, ethical problems and their idiosyncrasies need to be further explored. AIM: The objectives of this study were, first, to obtain a transcultural Portuguese-language adaptation and validation of the Ethical Conflict Nursing Questionnaire-Critical Care Version and, second, to analyse Portuguese critical care nurses' level of exposure to ethical conflict and its characteristics. METHODS: A cross-cultural validation and descriptive, prospective and correlational study. The sample was made for 184 critical care nurses in 2016. ETHICAL CONSIDERATIONS: The study was authorised by Bioethics Commission of the University of Barcelona, the Associaçâo de Apoio ao Serviço de Cuidados Intensivos do Centro Hospitalar do Porto and the Sociedade Portuguesa de Enfermagem de Saúde Mental. FINDINGS: The Portuguese version of the Ethical Conflict Nursing Questionnaire-Critical Care Version was a valid and reliable instrument to measure exposure to conflict. Moral outrage was the most common type of conflict. The most problematic situations were the ineffectiveness of analgesic treatments, the administration of treatments considered futile and the mismanagement of resources.

Moral resilience through harmonised connectedness in intensive care nursing: A grounded theory study.

OBJECTIVES: To examine intensive care nurses' main concerns in respect of ethical practice, and to investigate how nurses continue to practise in an ethical way despite challenges in order to offer a conceptualisation of moral resilience. RESEARCH METHODOLOGY/DESIGN: This qualitative study followed Glaser and Strauss' version of grounded theory. The study was reviewed, and approved, by research ethics committees in Switzerland and in England. MAIN OUTCOME MEASURES: Data consisted of field notes and in-depth interviews with 16 nurses working in intensive care in Switzerland and memos developed during the analysis. Data analysis followed the constant comparative method. This study took place between 2014 and 2017. FINDINGS: This study identified new understanding in how intensive care nurses manage their concerns and challenges regarding moral practice. The main category for moral resilience is harmonising connectedness, which represents intensive care nurses' main concern with regard to their moral life, and at the same time, represents the pattern of behaviour in their social interactions and what they yearn for. CONCLUSIONS: This study offers new insight into intensive care nurses' moral practice, moral resilience and strategies nurses use to achieve moral wellbeing.

Palliative Care and Moral Distress: An Institutional Survey of Critical Care Nurses.

BACKGROUND: The need for palliative care in the intensive care unit is increasing. Whether gaps and variations in palliative care education and use are associated with moral distress among critical care nurses is unknown. OBJECTIVES: To examine critical care nurses' perceived knowledge of palliative care, their recent experiences of moral distress, and possible relationships between these variables. METHODS: In this quantitative, descriptive study, survey questionnaires were distributed to 517 critical care nurses across 7 intensive care units at an academic health center in Virginia. Validated instruments were used to measure participants' perceptions of palliative care in their practice setting and their recent experiences of moral distress. RESULTS: A total of 167 completed questionnaires were analyzed. Fewer than 40% of respondents reported being highly competent in any palliative care domain. Most respondents had little palliative care education, with 38% reporting none in the past 2 years. Most respondents reported moral distress during the study period, and moral distress levels differed significantly on the basis of perceived use of palliative care (P = .03). Respondents who perceived less frequent use of palliative care tended to experience higher levels of moral distress. CONCLUSIONS: Many critical care nurses do not feel prepared to provide palliative care. When palliative care access is perceived as inadequate, nurses may be more apt to experience moral distress. Health system leaders should prioritize palliative care training for critical care nurses and their colleagues and empower them to reduce barriers to palliative care.

Determining the Moral Sensitivities of Intensive Care Nurses.

This article reports results from a descriptive study involving nurses working in intensive care units of hospitals in the province of Erzurum, eastern Turkey. A total of 110 nurses agreed to participate in the study. The Moral Sensitivity Questionnaire and a personal information form, which was developed by researchers in accordance with the relevant literature, were used for data collection. The results indicated that intensive care nurses face frequent ethical problem and that moral sensitivity is required to assist in coping with the issues. Researchers report that nurses who were highly satisfied with their work possessed a heightened sensitivity about ethical issues when compared with those who were dissatisfied with their profession.

Effects of an ethical empowerment program on critical care nurses' ethical decision-making.

BACKGROUND: Nurses require empowerment if they are to make ethical decisions. Ethical empowerment has always been one of the main concerns in nurse training programs. RESEARCH AIM: The present study was conducted to determine the effect of an ethical empowerment program on critical care nurses' ethical decision-making. RESEARCH DESIGN: This is a clinical trial study with two groups and pre and post design. PARTICIPANTS AND RESEARCH CONTEXT: In this study, 60 nurses working in Intensive Care Unit were selected through random sampling and then divided into a control and an experimental group after filling out the Moral Sensitivity Questionnaire. Both groups completed the questionnaire again immediately and 2 months after the ethical empowerment workshop had been held for the experimental group. The collected data were analyzed in SPSS-16 using descriptive and inferential statistics. ETHICAL CONSIDERATIONS: The goals of the study were explained to the participants and then a written informed consent was received from them. FINDINGS: The results showed no significant differences between the two groups in terms of their ethical sensitivity scores at the beginning of the study; however, immediately and 2 months after the intervention, the mean score increased significantly in the experimental group. Moreover, the scores obtained 2 months after the workshop increased compared to the pre-intervention scores but showed a drop compared to the scores reported immediately after the workshop. DISCUSSION: The ethical empowerment program, given to the critical care nurses in this study, improved their ethical sensitivity in making decisions significantly over time. Despite the extensive methods, available for teaching nursing ethics, the ethical empowerment program, adopted in this study, had long-lasting effects in terms of ameliorating the process of ethical decision-making in clinical situations. CONCLUSION: The ethical empowerment of nurses requires the adoption and application of proper methods and patterns of complying with nursing ethics.

Ethical conflict among nurses working in the intensive care units.

BACKGROUND: Ethical conflict is a barrier to decision-making process and is a problem derived from ethical responsibilities that nurses assume with care. Intensive care unit nurses are potentially exposed to this phenomenon. A deep study of the phenomenon can help prevent and treat it. OBJECTIVES: This study was aimed at determining the frequency, degree, level of exposure, and type of ethical conflict among nurses working in the intensive care units. RESEARCH DESIGN: This was a descriptive cross-sectional research. PARTICIPANTS AND RESEARCH CONTEXT: In total, 382 nurses working in the intensive care units in Iranian hospitals were selected using the random sampling method. Data were collected using the Ethical Conflict in Nursing Questionnaire-Critical Care Version (Persian version). ETHICAL CONSIDERATIONS: This study was approved by the Medical Research Ethics Committee. Ethical considerations such as completing the informed consent form, ensuring confidentiality of information, and voluntary participation were observed. FINDINGS: The results showed that the average level of exposure to ethical conflict was 164.39 ± 79.06. The most frequent conflict was related to "using resources despite believing in its futility," with the frequency of at least once a week or a month (68.6%, n = 262). The most conflictive situation was violation of privacy (76.9%, n = 294). However, the level of exposure to ethical conflict according to the theoretical model followed was the situation of "working with incompetent staff." The most frequently observed type of conflict was moral dilemma. CONCLUSION: The moderate level of exposure to ethical conflict was consistent with the results of previous studies. However, the frequency, degree, and type of ethical conflict were different compared to the results of other studies. Recognizing ethical conflict among intensive care unit nurses can be useful as it allows to consolidate those measures that favor low levels of ethical conflict, design appropriate strategies to prevent ethical conflicts, and improve the nursing work environment.

Limitation of therapeutic effort experienced by intensive care nurses.

BACKGROUND:: Nurses who practice limitation of therapeutic effort become fully involved in emotionally charged situations, which can affect them significantly on an emotional and professional level. OBJECTIVES:: To describe the experience of intensive care nurses practicing limitation of therapeutic effort. METHOD:: A qualitative, phenomenological study was performed within the intensive care units of the Madrid Hospitals Health Service. Purposeful and snowball sampling methods were used, and data collection methods included semi-structured and unstructured interviews, researcher field notes, and participants' personal letters. The Giorgi proposal for data analysis was used on the data. ETHICAL CONSIDERATIONS:: This study was approved by the Ethical Research Committee of the relevant hospital and by the Ethics Committee of the Rey Juan Carlos University and was guided by the ethical principles of voluntary enrollment, anonymity, privacy, and confidentiality. RESULTS:: In total, 22 nurses participated and 3 themes were identified regarding the nurses' experiences when faced with limitation of therapeutic effort: (a) experiencing relief, (b) accepting the medical decision, and (c) implementing limitation of therapeutic effort. CONCLUSION:: Nurses felt that, although they were burdened with the responsibility of implementing limitation of therapeutic effort, they were being left out of the final decision-making process regarding the same.

Compassionate care during withdrawal of treatment: A secondary analysis of ICU nurses' experiences.

BACKGROUND:: Withdrawal of treatment is a common practice in intensive care units when treatment is considered futile. Compassion is an important aspect of care; however, it has not been explored much within the context of treatment withdrawal in intensive care units. OBJECTIVES:: The aim was to examine how concepts of compassion are framed, utilised and communicated by intensive care nurses in the context of treatment withdrawal. DESIGN:: The study employed a qualitative approach conducting secondary analysis of an original data set. In the primary study, 13 nurses were recruited from three intensive care units within a large hospital in United Kingdom. Deductive framework analysis was used to analyse the data in relation to compassionate care. ETHICAL CONSIDERATIONS:: The primary study was approved by the local Research Ethics Committee and the hospital's Research and Development services. FINDINGS:: Compassionate care was mostly directed to the patient's family and was demonstrated through care and emotional support to the family. It was predominantly expressed through attempts to maintain the patient's dignity by controlling symptoms, maintaining patient cleanliness and removing technical apparatus. CONCLUSION:: This study's findings provide insight about compassionate care during treatment withdrawal which could help to understand and develop further clinicians' roles. Prioritising the family over the patient raised concerns among nurses, who motivated by compassion, may feel justified in taking measures that are in the interests of the family rather than the patient. Further work is needed to explore the ethics of this.

Reconciling conceptualizations of ethical conduct and person-centred care of older people with cognitive impairment in acute care settings.

Key commentators on person-centred care have described it as a "new ethic of care" which they link inextricably to notions of individual autonomy, action, change and improvement. Two key points are addressed in this article. The first is that few discussions about ethics and person-centred are underscored by any particular ethical theory. The second point is that despite the espoused benefits of person-centred care, delivery within the acute care setting remains largely aspirational. Choices nurses make about their practice tend to comply more often with prevailing norms than those championed by person-centred care. We draw on elements of work by moral philosopher Løgstrup and Foucault to provide insight into nurses' ethical conduct and ask why nurses would want to act otherwise, when what they think and do is viewed as normal, or think and act otherwise if doing so is seen within the organization as transgressive? To address these more specific questions, we discuss them in relation to the following constructs: the ethical demand, sovereign expressions of life and parrhêsia. We conclude by arguing that a ethical theoretical framework enables nurses to increase their perceptibility and appreciation of the ethical demand particularly those emanating from incommensurability between organizational norms and the norms invoked by person-centred care. We argue that nurses' responses to the ethical demand by way of parrhêsia can be an important feature of intra-organizational reflexivity and its transformation towards the delivery care that is more person-centred, particularly for older people with cognitive impairment. We conclude the article by highlighting the implications of this for nursing education and research.