Early indicators and risk factors for ethical issues in clinical practice.

PURPOSE: Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify risk factors and early indicators of ethical conflicts. METHODS: Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, their risk factors and early indicators, nurse actions, and situational outcomes. Two nurse researchers independently analyzed and categorized data using a constant comparison technique. FINDINGS: Most of the ethically difficult situations pertained to end-of-life care for children and adults. Conflicts in interpersonal relationships were prevalent. Nurses were especially moved by patient and family suffering and concerned about patient vulnerability, harm-benefit ratio, and patient autonomy. Researchers discovered risk factor categories for patients, families, healthcare providers, and health systems. Additionally, researchers found subcategories in six major categories of early indicators: signs of conflict, patient suffering, nurse distress, ethics violation, unrealistic expectations, and poor communication. CONCLUSIONS: Nurses are keenly aware of pertinent risk factors and early indicators of unfolding ethical conflicts. Many nurses reported feeling powerless in the face of ethical conflict. Research that develops interventions to strengthen nurses' voices in ethically difficult situation is warranted. CLINICAL RELEVANCE: Nurses are in a key position to identify patient situations with a high risk for ethical conflict. Initiating early ethics consultation and interventions can alter the course of pending conflicts and diminish the potential for patient and family suffering and nurses' moral distress.

Nursing priorities, actions, and regrets for ethical situations in clinical practice.

PURPOSE: Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify priorities, action responses, and regrets. METHODS: Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, nurse actions, and situational outcomes. Data on nursing priorities and actions were analyzed and categorized using a constant comparison technique. FINDINGS: Addressing patient autonomy and quality of life were ethical priorities in the majority of cases. In many cases, nurses analyzed ethics from a diffuse perspective and only considered one dimension of the ethics conflict. However, some nurses were specific in their ethical analysis and proactive in their action choices. Nurses also identified 12 ethics-specific nurse activities, five ways of being, three ways of knowing, and two ways of deliberating. In 21 cases, nurses chose not to pursue their concerns beyond providing standard care. Several nurses expressed significant regret in their narration; most regretted unnecessary pain and suffering, and some claimed they did not do enough for the patient. CONCLUSIONS: Not enough specific, evidence-based ethics actions have been developed. Stronger and more proactive nursing voices with early ethics interventions would make valuable contributions to quality of care for patients, especially at the end of life. CLINICAL RELEVANCE: Ever-expanding treatment options raise ethical issues and challenge nurses to be effective patient advocates. Evidence-based nursing interventions that promptly identify and address moral conflict will benefit patients, their families, and the entire healthcare team by mitigating potential moral distress and disengagement.

Expanding nurses' participation in ethics: an empirical examination of ethical activism and ethical assertiveness.

This research project investigated the extent to which nurses engage in two important kinds of ethical behaviours: ethical activism (where they try to make hospitals more receptive to nurses' participation in ethics deliberations) and ethical assertiveness (where they participate in ethics deliberations even when not formally invited). This research probed not only the extent to which nurses engage in these ethical behaviours but also whether this is influenced by professional, training and organizational factors. A random sample of 165 nurses from three major hospitals in Los Angeles provided the data. Regression analyses indicate that both ethical activism and ethical assertiveness are strongly influenced by nurses' perceptions of the receptivity of hospitals to their inclusion in ethics deliberations. In addition, nurses' education in ethics is a significant predictor of ethical activism. The findings have important implications for the content of nurses' ethics training as well as for expanding the boundaries of nurses' participation in ethics deliberations. The authors define ethics deliberations as specific meetings of a number of people to discuss an ethical issue, such as one regarding the care of a patient.