Concept analysis of conscience-based nursing care: a hybrid approach of Schwartz-Barcott and Kim's hybrid model.

BACKGROUND: The nursing profession considers conscience as the foundation and cornerstone of clinical practice, which significantly influences professional decision-making and elevates the level of patient care. However, a precise definition of conscience in the nursing field is lacking, making it challenging to measure. To address this issue, this study employed the hybrid approach of Schwartz Barcott and Kim to analyze the concept of conscience-based nursing care. METHODS: This approach involves a three-phase process; theoretical, fieldwork, and analytical. A systematic literature review was conducted using electronic databases during the first phase to find relevant papers. The content of 42 articles that met the inclusion criteria was extracted to determine the attributes, antecedents, and consequences of consciousness care using thematic analysis. Based on the working definition as a product of this phase, the plan of doing the fieldwork phase was designed. During this phase, data were collected through interviews with nurses all of whom were responsible for patient care in hospitals. In this phase, 5 participants were chosen for in-depth interviewing by purposeful sampling. Data were analyzed using directed content analysis. The findings of the theoretical and fieldwork phases were integrated and the final definition was derived. RESULTS: The integration of the theoretical and fieldwork phases resulted in identifying four key characteristics of conscience-based nursing care. Firstly, it involves providing professional care with a conscientious approach. Secondly, ethics is at the core of conscience-based care. Thirdly, external spirituality plays a significant role in shaping one's conscience in this context. Finally, conscience-based nursing care is both endogenous and exogenous, with professional commitment being the central focus of care. CONCLUSION: Conscience-based nursing care is an essential component of ethical care, which elevates clinical practice to professional care. It requires the integration of individual and social values, influenced by personal beliefs and cultural backgrounds, and supported by professional competence, resources, and a conducive organizational atmosphere in the healthcare field. This approach leads to the provision of responsive care, moral integrity, and individual excellence, ultimately culminating in the development of professionalism in nursing.

Ethical Decision-Making Confidence and Professional Values Among Nurse Leaders.

OBJECTIVES: The aims of this study were to describe differences in nurse leaders' ethical decision-making confidence and their professional values based on identified characteristics and to explore the relationship between ethical decision making and professional values. BACKGROUND: Nurse leaders have multiple duties and obligations toward their patients, other staff, and the organizations where they work. However, ethical decisions can be complex, requiring the guidance of professional values and critical appraisal of the situation. METHODS: This study was conducted using a correlational design. Convenience sampling was used, resulting in a sample of 56 nurse leaders in various positions. RESULT: Ethical decision making and professional values were found to be strongly correlated. CONCLUSION: Ethical decision making and professional values are highly correlated in this sample. Understanding the importance of the effects of certain factors on ethical decision making can assist in forming an environment supportive of ethical practices for nurses.

Nurses' moral courage and related factors: A systematic review.

BACKGROUND: Nurses face various ethical conflicts when taking care of patients, and such conflicts require moral courage. This systematic review was conducted with the aim of investigating moral courage and its related factors among nurses. METHODS: To find related studies, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. The PubMed, Web of Science, Google Scholar, Scopus, Embase and Science Direct databases were searched using keywords such as Courage, Moral Courage, and Nurses, and no lower time limit was imposed when conducting the searches. The identified studies were published between January 2000 and March 2023. Quality of articles was assessed using the STROBE checklist. RESULTS: The pooled sample size for the 19 included studies was 7863. All studies were observational and cross-sectional. The results showed that three categories of factors most related to moral courage are individual, moral, and factors related to the organization. Underlying factors of each category are also provided within this paper. CONCLUSION: Moral courage is an integral part of nursing, which as a profession, is becoming even more challenging with the advancement of science and technology. Therefore, there is a need for nurses and especially nursing managers to be considerate of factors affecting moral courage of nurses, with a view to strengthening the positive factors and reducing the negative impacts.

Brave spaces in nursing ethics education: Courage through pedagogy.

BACKGROUND: Nursing students must graduate prepared to bravely enact the art and science of nursing in environments infiltrated with ethical challenges. Given the necessity and moral obligation of nurses to engage in discourse within nursing ethics, nursing students must be provided a moral supportive learning space for these opportunities. Situating conversations and pedagogy within a brave space may offer a framework to engage in civil discourse while fostering moral courage for learners. RESEARCH OBJECTIVE: The aim of this research is to explore the influence of a structured self-assessment tool called the ESA "Engagement Self-Assessment" on the alignment and creation of a brave space in a nursing ethics course. RESEARCH DESIGN: This study used an exploratory, cross-sectional survey design. PARTICIPANTS AND STUDY SETTING: Data from 39 undergraduate nursing students enrolled in a nursing healthcare ethics & law course using the ESA were recruited. ETHICAL CONSIDERATIONS: Participation was voluntary and informed without coercion. Written consent was obtained prior to participation. Research ethics approval was obtained by the Institutional Research Ethics Board of the recruited participants (Ethics # 2022-23-03). FINDINGS: The ESA provided structured self-reflection on the impact of shared vulnerability within a brave space. However, commitment to a brave space was not strongly influenced by the ESA, but rather by a mutual "commitment to others." CONCLUSION: A teaching tool such as an ESA can be used to facilitate instructor expectations of civil discourse and discussion of difficult topics. Rules of engagement such as those found in brave spaces can help transform fear of vulnerability into authentic growth for learners. A morally supportive learning space can support critical opportunities for ethical development. This study provides insight into how self-assessment and the use of a brave space in nursing ethics education can facilitate a morally supportive learning space.

Characteristics of a good nurse as perceived by nurses.

BACKGROUND: Nursing is a humanitarian and social field that provides health services. It combines science and art and has a rich history. Despite fundamental changes in the provision of medical services and nursing education, the concept of "good nurse" is still unclear. PURPOSE: The purpose of this article is to investigate the characteristics of a good nurse from the nurses' perspective. RESEARCH DESIGN AND METHOD: A qualitative study was applied using conventional content analysis. The participants were 30 nurses that selected with purposive sampling method. Data were collected through unstructured interviews and simultaneously analyzed via the conventional content analysis approach of Graneheim and Lundman. ETHICAL CONSIDERATIONS: This study was approved by the Research Ethics Committee of Hormozgan University of Medical Sciences, Iran. FINDINGS: The study revealed that personal characteristics (Adherence to ethical and human principles, Physical health, Attractive appearance, and Ability to communicate properly); and professional characteristics (knowledge - clinical skill - nursing roles) are essential to being a good nurse. CONCLUSION: Coming to know the distinctive features of a good nurse as perceived by nurses themselves creates an opportunity for nurses to rethink their profession and to reflect on the characteristics of the good nurse.

Am I my students' nurse? Reflections on the nursing ethics of nursing education.

Despite having worked in higher education for over twenty years, I am still, first and foremost, a practicing nurse. My employer requires me to be a nurse and my regulator regards what I do as nursing. My practice is regulated by the Code and informed by nursing ethics. If I am nurse, practicing nursing, does that mean that my students are my patients? This paper considers how the relationship that I have with my students can be informed by the ethics of the nurse/patient relationship. After some initial theoretical preparation concerning argument from analogy, the paper identifies some areas for comparison between the two relationships. Areas of similarity and difference identify two areas of concern: Nurse education and educators regularly engage in coercion and surveillance in an attempt to increase student success, both of which would be considered outside nursing ethics. It is concluded that these coercive practices are not conducive to an environment where character is cultivated. Despite current financial and workforce pressures, nurse lecturers and more especially their managers would do well to return to the professional ethics of nursing to question and guide their practice.

Re-examining the relationship between moral distress and moral agency in nursing.

In recent years, the phenomenon of moral distress has been critically examined-and for a good reason. There have been a number of different definitions suggested, some that claimed to be consistent with the original definition but in fact referred to different epistemological states. In this paper, we re-examine moral distress by exploring its relationship with moral agency. We critically examine three conceptions of moral agency and argue that two of these conceptions risk placing nurses' values at the center of moral action when it ought to be the patient's values that shape nurses' obligations. We propose that the conception of moral agency advanced by Aimee Milliken which re-centers patient values, should be more broadly accepted within nursing. We utilize a case example to demonstrate a situation in which the values of a patient's parents (surrogates) justifiably constrained nurses' moral agency, creating moral distress. Through an examination of constraints on nurse agency in this case, we illustrate the problematic nature of 'narrow' moral distress and the value of re-considering moral distress.  Finally, we provide an action-oriented proposal identifying mediating steps that we argue have utility for nurses (and other healthcare professionals) to mediate between experiences of narrow moral distress and the exercise of moral agency.

From informed to empowered consent.

Informed consent is ethically incomplete and should be redefined as empowered consent. This essay challenges theoretical assumptions of the value of informed consent in light of substantial evidence of its failure in clinical practice and questions the continued emphasis on autonomy as the primary ethical justification for the practice of consent in health care. Human dignity-rather than autonomy-is advanced from a nursing ethics perspective as a preferred justification for consent practices in health care. The adequacy of an ethic of obligation (namely, principlism) as the dominant theoretical lens for recognising and responding to persistent problems in consent practices is also reconsidered. A feminist empowerment framework is adopted as an alternative ethical theory to principlism and is advanced as a more practical and complete lens for examining the concept and context of consent in health care. To accomplish this, the three leading conceptions of informed consent are overviewed, followed by a feminist critique to reveal practical problems with each of them. The need for a language change from informed to empowered consent is strongly considered. Implications for consent activities in clinical practice are reviewed with focused discussion on the need for greater role clarity for all involved in consent-beyond and inclusive of the patient-physician dyad, as the practice and improvement of consent is necessarily a transdisciplinary endeavour. Specific concrete and practical recommendations for leveraging nursing expertise in this space are presented. Perhaps what is most needed in the discourse and practice of consent in health care is nursing.

Another nursing is possible: Ethics, political economies, and possibility in an uncertain world.

Overtaxed by the realities laid bare in the pandemic, nursing has imminent decisions to make. The exigencies of pandemic times overextend a health care infrastructure already groaning under the weight of inequitable distribution of resources and care commodified for profit. We can choose to prioritise different values. Invoking philosopher of science Isbelle Stengers's manifesto for slow science, this is not the only nursing that is possible. With this paper, I pick up threads of nursing's historical ontology, drawing previous scholarship on the historical narratives nurses use to understand themselves. Peeling back nursing's myth to alternate points of origin allows me to consider alternate lines of flight, a speculative adventure in paths not taken but paths that exist nonetheless. I go on to examine what a collective ethic of nursing could be, when we make space for these alternate histories, considering the confluences and conflicts that enable nurses to care and those that inhibit them from doing so. The imperative for this lies in the central importance of the reproductive labour of nursing health care, which leads me to a critique of nursing's capitulation to the pressures of late stage capitalism. This is a problem with ethical and ontological implications both for nursing, and also for those who require nursing care, an imperative to think about the kinds of present/futures for health, care, and health care we might cocreate in collaboration and solidarity with the communities in which nurses are imbricated, shedding the trappings of neoliberalism. There is significant power in the vision and praxis of 28 million nurses and midwives worldwide. Our ethics can guide our imagination which can in turn create possibility. This kind of endeavour-that of dreams and imagination-leads us to what could be, if only we leap.

Christian Ethical Foundations of Modern Nursing in China.

ABSTRACT: The influence of Western Christian missionary nurses has been recorded in the history and development of nursing in China. The purpose of this study was to investigate the influence of Christianity on Chinese nursing ethics. This documentary research used content analysis to investigate Christian value trends over 13 years (1920-1932) as reflected in a major bilingual Chinese nursing journal.

Christian Worldview and Caring in Nursing: The Legacy of Sister Simone Roach.

ABSTRACT: Sister Simone Roach, a noted philosopher of caring in nursing, left behind a significant body of theoretical and practical work highlighting the areas of nursing ethics, care/caring, and compassion. This article explores the integration of the moral foundation of agape love in Pauline theology and Roach's human caring in nursing (1992) as the action of agape love. A narrative literature review explores the relationship between the scriptural ethics of St. Paul (Pauline ethics) and Roach's caring in nursing.

The effect and comparison of training in ethical decision-making through lectures and group discussions on moral reasoning, moral distress and moral sensitivity in nurses: a clinical randomized controlled trial.

BACKGROUND: Ethical decision­making and behavior of nurses are major factors that can affect the quality of nursing care. Moral development of nurses to making better ethical decision-making is an essential element for managing the care process. The main aim of this study was to examine and comparison the effect of training in ethical decision-making through lectures and group discussions on nurses' moral reasoning, moral distress and moral sensitivity. METHODS: In this randomized clinical trial study with a pre- and post-test design, 66 nurses with moral reasoning scores lower than the average of the community were randomly assigned into three equal groups (n = 22) including two experimental groups and one control group. Ethical decision-making training to experimental groups was provided through the lectures and group discussions. While, the control group did not receive any training. Data were collected using sociodemographic questionnaire, the nursing dilemma test (NDT), the moral distress scale (MDS) and the moral sensitivity questionnaire (MSQ). Unadjusted and adjusted binary logistic regression analysis was reported using the odds ratio (OR) and 95% confidence intervals. RESULTS: Adjusted regression analysis showed that the probability of increasing the nursing principle thinking (NPT) score through discussion training was significantly higher than lecture (OR: 13.078, 95% CI: 3.238-15.954, P = 0.008), as well as lecture (OR: 14.329, 95% CI: 16.171-2.005, P < 0.001) and discussion groups compared to the control group (OR: 18.01, 95% CI: 22.15-5.834, P < 0.001). The possibility of increasing moral sensitivity score through discussion training was significantly higher than lecture (OR: 10.874, 95%CI: 6.043-12.886, P = 0.005) and control group (OR: 13.077, 95%CI: 8.454-16.774, P = 0.002). Moreover, the moral distress score was significantly reduced only in the trained group compared to the control, and no significant difference was observed between the experimental groups; lecture group vs. control group (OR: 0.105, 95% CI: 0.015-0.717, P = 0.021) and discussion group vs. control group (OR: 0.089, 95% CI: 0.015-0.547, P = 0.009). CONCLUSIONS: The results of this study indicate that ethical decision-making training is effective on empowerment of ethical reasoning. Whereas the group discussion was also effective on increasing the ethical sensitivity, it is recommended the training plan provided in this study to be held as workshop for all nurses in health and treatment centers and placed in curricular plan of nursing students. REGISTRATION: This randomized clinical trial was registered in Iranian Registry of Clinical Trials under code (IRCT2015122116163N5) in 02/07/2016.

When nurses' vulnerability challenges their moral integrity: A discursive paper.

BACKGROUND: Both vulnerability and integrity represent action-guiding concepts in nursing practice. However, they are primarily discussed regarding patients-not nurses-and considered independently from rather than in relation to each other. AIM: The aim of this paper is to characterize the moral dimension of nurses' vulnerability and integrity, specify the concepts' relationship in nurses' clinical practice and, ultimately, allow a more fine-grained understanding. DESIGN: This discursive paper demonstrates how vulnerability and integrity relate to each other in nursing practice and carves out which types of vulnerability pose a threat to nurses' moral integrity. The concept of vulnerability developed by Mackenzie et al. (2014) is applied to the situation of nurses and expanded to include the concept of moral integrity according to Hardingham (2004). Four scenarios are used to demonstrate where and how nurses' vulnerabilities become particularly apparent in clinical practice. This leads to a cross-case discussion, in which the vulnerabilities identified are examined against the background of moral integrity and the relationship between the two concepts is determined in more detail. RESULTS AND CONCLUSION: Vulnerability and integrity do not only form a conceptual pair but also represent complementary moral concepts. Their joint consideration has both a theoretical and practical added value. It is shown that only specific forms of vulnerability pose a threat to moral integrity and the vulnerability-integrity relationship is mediated via moral distress. IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE: The manuscript provides guidance on how the concrete threat(s) to integrity can be buffered and moral resilience can be promoted. Different types of threats also weigh differently and require specific approaches to assess and handle them at the micro-, meso- and macro-level of the healthcare system.

The relationship between ethical position and whistleblowing: A cross-sectional study among nurses.

AIM AND OBJECTIVES: The aim of this study is to determine nurses' ethical positions, whistleblowing intention and its causes, and to analyse the correlation between them, while revealing the personal and professional characteristics causing significant difference. BACKGROUND: In today's challenging healthcare settings, ethical dilemmas are inherent to nursing practices, leading to situations whereby nurses must consider whistleblowing and reasons such as reporting medical errors or misbehaviors. DESIGN: The study is descriptive, cross-sectional and correlational. METHODS: The data were collected from a convenience sample consisting of 294 nurses between 1 April and 30 June 2019, in four hospitals in two cities. An introductory information form, Ethics Position Questionnaire, Whistleblowing Scale and Causes of Whistleblowing Scale were employed to collect data. The data were analysed with descriptive, correlational, comparative and internal consistency analyses (Guidelines for reporting cross-sectional studies (Data S1)). RESULTS: It was found that nurses encountered (31.3%) and reported (85.9%) unethical incidents. According to the subscales, they obtained higher scores from idealism (4.37 ± 0.52), supportive whistleblowing (3.75 ± 0.72), and moral and professional values (3.77 ± 0.67). The Ethics Position Questionnaire, as well as the Whistleblowing Scale (r = .302) and the Causes of Whistleblowing Scale (r = .211) had a positive weak correlation (p < .001). Nurses' age, marital status, and professional and institutional experiences all created a significant difference (p < .05). CONCLUSIONS: The nurses mostly encountered unethical incidents associated with management. The rates of reporting the unethical incidents were high, and they were found not hesitating to report using whistleblowing, yet intended to keep the incidents within the institution. In addition, idealistic nurses were more likely to whistleblow, and their causes for whistleblowing were mostly associated with moral and professional values. RELEVANCE TO CLINICAL PRACTICE: It is recommended that nurses' ethical position, and whistleblowing intentions and causes should be supported and improved through the corporate culture.

Dignity in nursing: A bibliometric and visual analysis of scientific publications.

BACKGROUND: Dignity-conserved nursing has been widely studied by scholars all over the world; however, there is no clear direction in which this field is trending. AIM: To conduct a bibliometric analysis that systematically characterises publications on dignity research in the nursing field from 2011 to 2020. DESIGN: Bibliometric and visual analysis of retrieved articles. METHODS: The Web of Science Core Collection database was used to retrieve all articles which addressed dignity in nursing from 2011 to 2020. The WoSCC's own analysis tool, CiteSpace and VOSviewer, were used to obtain visual analysis results. Reporting follows the STROBE checklist. RESULTS: A total of 1429 papers on dignity care are included in this study. We found that the number of papers on this topic increased steadily, and the United States topped the list with 366 articles in total. The institute with the most publications was King's College London, and the most widely published journal was Nursing Ethics. We were able to identify four major research topics, namely dignity in: (a) palliative care, (b) dementia and the elderly, (c) health care and (d) nursing ethics. Terminally ill patient, home, value, rehabilitation and psychological distress were the five keywords with the highest burst strength. CONCLUSIONS: The interest in dignity care research has been steadily increasing from 2011 and is reflected in the number of published papers. The United States and Western Europe are leading in this field, both having a high number of cutting-edge researchers and high-level scientific research institutions. In the domain of dignity care, several stable and high-yield core author groups have been formed. While the existing research mainly focuses on four hot spots, psychological distress, advanced cancer, maternity care and content analysis may be the research frontiers.

Applying a Foucauldian lens to the Canadian code of ethics for registered nurses as a discursive mechanism for nurses professional identity.

This study examines the Canadian Code of Ethics for Registered Nurses as a discursive mechanism for shaping nurses' professional identity using a Foucauldian lens. Nurses are considered essential in healthcare, yet the nursing profession has struggled to be recognized for its discipline-specific knowledge and expertise and, as such, has remained the subject of and subject to the dominant discourses within healthcare and society generally. Developing a professional identity in nursing begins after the necessary education and training are achieved and embodies the profession's history, values, code of ethics, and expectations of the profession that distinguish it from other professions. Since nurses' professional identity is shaped through discourse, it raises the question of whether there are spaces to reconceptualize nurses' subject position within health care. Since professional identity is considered the embodiment of knowledge and practice, the code of ethics bears examination both for its effect on nurses' professional identity and as a potential site from which to challenge hegemonic assumptions. This article discusses the concept of professional identity in nursing and its development through the discursive formations in the code of ethics. The sources of power/knowledge are examined as both mechanisms of control and as spaces for change.

COVID-19 as moral breakdown: Entangled ethical demands experienced by hospital-based nurses in the early onset of the pandemic.

2020 saw the rapid onset of a global pandemic caused by the SARS-CoV-2 virus. For healthcare systems worldwide, the pandemic called upon quick organization ensuring treatment and containment measures for the new virus disease. Nurses were seen as constituting a vital instrumental professional component in this study. Due to the pandemic's unpredictable and potentially dangerous nature, nurses have faced unprecedented risks and challenges. Based on interviews and free text comment from a survey, this study explores how ethical challenges related to "being a nurse" during the COVID-19 pandemic was experienced and understood by Danish hospital-based nurses. Departing from anthropologist Jarett Zigon's notion of moral breakdown, the study demonstrates how the rapid onset of the pandemic constitutes a moral breakdown raising ethical demands for nurses. Analytically we identify three different ethical demands experienced by the nurses. These ethical demands are Nursing and societal ethical demands, Nursing and personal ethical demands, and Nursing and conflicting ethical demands. These demands represent not only very different understandings of ethical demands but also different understandings of ethical acts that are seen as necessary to respond to these demands.

The Ethics Resource Caregiver Program: Equipping Nurses as Ethics Champions.

AbstractBackground: Nurses face ethical issues and experience moral distress in their everyday work. A nursing ethics champion program was developed at a hospital in the United States. METHODS: As part of a quality improvement project, pre- and post-training surveys were developed to assess whether the program was feasible and sustainable, enhanced nurse confidence in recognizing and addressing ethical issues and moral distress, and increased nurse knowledge of institutional resources for addressing the same. Qualitative and quantitative analyses were performed. RESULTS: Thirteen nurses from both the critical care and medical/surgical settings participated in the program. The program proved feasible. Attrition after the educational sessions raised concerns about sustainability. Survey results suggest an association between participating in the program's educational sessions and increased nurse confidence in recognizing and addressing ethical issues and moral distress, as well as identifying institutional resources that can assist nurses with the same. DISCUSSION: Opportunities for future nursing ethics champion programs include increasing the interactivity and duration of educational sessions, making programs multidisciplinary, and creating materials for nurses to more easily share with colleagues. It would be valuable for future research to measure the impact of nursing ethics champion programs on nursing turnover. IMPLICATIONS: A nursing ethics champion program has the potential to help nurses feel better equipped to navigate ethical issues and moral distress in their everyday work.

Nursing Ethics Liaison Program: A Pilot Study.

AbstractNursing is a profession rooted in ethics, yet nurses often find it difficult to navigate the ethical quandaries faced in clinical practice. The COVID-19 pandemic caused significant moral distress among staff. To support nurses and promote ethical reasoning, the Ethics Liaison Program for nursing was developed. The 36-hour program, run over nine months, proved to be highly effective in improving nurse work satisfaction, participant's confidence and knowledge about ethics and ethical reasoning, connectivity to the clinical ethics service, and patient care. This article describes program development, implementation, and evaluation.

Clinical nurse adherence to professional ethics: A grounded theory.

BACKGROUND: Professional ethics is the regulation and discipline of nurses' daily nursing work. Nurses often encounter various ethical challenges and problems in their clinical work, but there are few studies on nurses' adherence to professional ethics. RESEARCH AIM: An analysis of nursing adherence to nursing ethics from the perspective of clinical nurses in the Chinese public health system. RESEARCH DESIGN: This study adopts the grounded theory approach proposed by Strauss and Corbin. PARTICIPANTS AND RESEARCH CONTEXT: Between July 2021 and January 2022, Clinical nurses were recruited for online video interviews using purposive and theoretical sampling methods in seven hospitals in Beijing, Tianjin, Shanxi, Henan, Guangdong, and Fujian, China. Data analysis was conducted using Strauss and Corbin's coding approach. ETHICAL CONSIDERATIONS: This study was approved by the Ethics Committee of Sanming First Hospital (MingYiLun 71/2021). FINDINGS: A total of 27 participants were included. A theoretical model of nursing staff adherence to professional ethics was constructed. The main core was adherence to professional ethics and the other cores were (1) causal conditions: professional ethics code, individual conscience; (2) intervening conditions: personal growth, social support system, matching career compensation, prediction of adverse consequences; (3) action strategies: sticking to professional values, self-regulation, flexible response, post-event improvement; and (4) outcomes: self-harmony, reduced medical disputes. CONCLUSIONS: This study provides an interpretive understanding of why clinical nurses adhere to professional ethics in China and describes the challenges and issues posed by nurses' use of strategies to cope with ethical adversity. The findings can be used to develop future complex studies.