Everyday ethics: ethical issues and stress in nursing practice

“Additionally, the intensity in which nurses experience these ethical issues or problems can influence the degree to which they engage in moral behavior (Jones 1991).”

“Third, although our response rate was slightly lower than hoped for, it is consistent with mean response rates among surveys using nurse respondents (61± 23) (Asch et al, 1997).”

“This sense of powerlessness “fits” the classic definition of moral distress, where one knows the morally correct course of action but cannot carry it out due to situational and/or other internal and external constraints (Corley 2002; Corley et al. 2005).”

“This sense of powerlessness “fits” the classic definition of moral distress, where one knows the morally correct course of action but cannot carry it out due to situational and/or other internal and external constraints (Corley 2002; Corley et al. 2005).”

“…acute and long-term care (Crego & Lipp 1998; Burns et al. 2001; Redman & Fry 2003); conflict resolution in parent-childprovider relationships in pediatric care (Butz et al. 1998); and physician collaboration, autonomy, and insurance constraints in advanced practice (Laabs 2005; Ulrich et al. 2007).”

“Harrington and Smith (2008) note that “even clinicians who are well trained and skilled at giving bad news can find it burdensome and emotionally J Adv Nurs.”

“…2007; Epstein, 2008); initiating, withholding, and withdrawing treatment and advance directives in acute and long-term care (Crego & Lipp 1998; Burns et al. 2001; Redman & Fry 2003); conflict resolution in parent-childprovider relationships in pediatric care (Butz et al. 1998); and physician…”

“Ethics Stress Scale: In addition, we included a broader scale of ethics stress developed by Raines (2000) that was adapted to assess individual, organizational and societal effects of ethical decision-making in practice (e.g., powerlessness, fatigue, legal consequences, psychological effects).”

“…include ethical issues in restraint use in mental health (Redman & Fry, 2003); providing care to high risk neonates (van Zuuren & van Manen, 2006; Janvier et al. 2007; Kain, 2007; Epstein, 2008); initiating, withholding, and withdrawing treatment and advance directives in acute and long-term…”

“…use in mental health (Redman & Fry, 2003); providing care to high risk neonates (van Zuuren & van Manen, 2006; Janvier et al. 2007; Kain, 2007; Epstein, 2008); initiating, withholding, and withdrawing treatment and advance directives in acute and long-term care (Crego & Lipp 1998; Burns et…”

“…acute and long-term care (Crego & Lipp 1998; Burns et al. 2001; Redman & Fry 2003); conflict resolution in parent-childprovider relationships in pediatric care (Butz et al. 1998); and physician collaboration, autonomy, and insurance constraints in advanced practice (Laabs 2005; Ulrich et al. 2007).”

“…in restraint use in mental health (Redman & Fry, 2003); providing care to high risk neonates (van Zuuren & van Manen, 2006; Janvier et al. 2007; Kain, 2007; Epstein, 2008); initiating, withholding, and withdrawing treatment and advance directives in acute and long-term care (Crego & Lipp 1998;…”

“In a study of nurses' knowledge of advance directives at a large acute care hospital in the Midwest of the USA, Crego and Lipp (1998) found that a large majority of respondents thought that neither nurses nor patients had a good understanding of advance directives and that both needed more education.”

“Fry and Duffy (2001) developed and tested a tool (Ethical Issues Scale) to assess the full range of ethical issues experienced by nurses in current practice and the frequency of their occurrences.”

“2001; Redman & Fry 2003); conflict resolution in parent-childprovider relationships in pediatric care (Butz et al. 1998); and physician collaboration, autonomy, and insurance constraints in advanced practice (Laabs 2005; Ulrich et al.”

“N IH -PA Author M anuscript N IH -PA Author M anuscript N IH -PA Author M anuscript significant others (Levi et al. 2004).”

“Nurses seem to be doing more and more with these limited resources, but “Even when the provider does the best he or she can, it may not feel good enough” (Ulrich & Grady, 2009, p.5).”

“Nursing is a profession vital to the health and well-being of all nations and is the backbone of any healthcare system.(1) Monitoring nurses’ working conditions and improving the organizational climate of hospitals are likely to improve the safety of the employee and the profitability of the hospital through improved…”

“This, in turn, might lead to compromised moral integrity and generate moral distress [11, 15, 16], as these reactions result from acting or not acting on the basis of one’s own sense of right and wrong [17].”

“Ulrich et al.(67) Stagg(68) Milton(69) Hoyt(70) Gropelli,(71) McCrink,(72) Fairchild(73) Reagan,(74) Park,(5) Milton(21) Callister et al.”

“, 2010), not meeting patient desires/ rights (Cooper et al., 2004; Ulrich et al., 2010), poor communication or lack of communication/honesty (Cooper et al.”

“Several studies have highlighted ethical questions that have arisen as a result of the high moral distress that nurses experience in practice (Ulrich et al. 2010, Dekeyser Ganz & Berkovitz 2012, Oh & Gastmans 2013, Wocial & Weaver 2013).”

“CES is becoming more prevalent with the increased awareness worldwide of the importance of ethical issues in healthcare and with personnel encountering an increasing number of ethical issues in clinical practice (Bartholdson et al. 2015; Doran et al. 2015; Oberle and Hughes 2001; Ulrich et al. 2010).”

“Conflict with doctors, identified in situations where the care prescribed and often delivered by nurses did not match the nurses’ perception of what was ethical, fair or in-line with patients and their families’ wishes.(33,41,44) Collaboration within decision-making involving others brings a range of perspectives, inc…”

“Ethical issues that nurses’ face include end-of-life issues,(3,28,36) staffing patterns,(3) nurse-physician conflicts,(28) adequacy of resources,(37) and protecting human rights and dignity.(3,28) One solution that health care providers sometimes turn to is conscientious objection, defined as opting out of clinical pr…”

“This lack of clarity and subsequent inaction may lead to moral distress and moral residue and ultimately impact the hospital’s ability to retain nurses.(4,5)”

“In Finland, for example, there are new regulations for patient’s right to choose their place of care28 and for electronic pages for citizens where they may read their own documents entered in the Prescription Centre or electronic Patient Data Archive.29 Protection of patients’ rights is reported to be nurses’ most fre…”

“This may be done through regular and combined training sessions for doctors, physicians and nurses [68].”

“Such findings are mirrored in other research, and again and again similar comments appear in a great number of related research and literature about moral distress in nursing.(17,19,20,50,51) Finally, perhaps most disturbing of all in the New Zealand research was the finding that younger nurses are more susceptible to…”

“Advances in medical technology, scarcity of resources, as well as uncertain and complex clinical problems are imposing stubborn problems on nurses [4].”

“Unlike the findings of the studies carried out by Cronqvist et al.16 and Ulrich et al.,5 participants showed no moral distress and/or frustration, which can be associated to the difficulty in recognizing ethical issues in their daily practice, in conjunction with the fact that patients are unable to communicate and, c…”

“In the study conducted by Ulrich et al.(13) on ethical problems and stress in nursing practices, it was reported that young and less experienced nurses experienced more ethical problems and higher stress.”

“Interventions can lead to evidence to promote ethical best practice.(6,15) Ethical quality is important in all fields of healthcare, so the need for intervention studies is general, and requires multi-disciplinary collaboration.”

“…nurses often lack sufficient expertise in evaluating ethical matters, are not always capable of recognizing ethical issues (Atabay, Ҫangarli, & Penbek, 2015; Corley, 2002; Ulrich et al., 2010) and are not always aware of the ethical decisions they face and make (Storaker, Nåden, & Sæteren, 2017).”

“Ulrich et al. (2010) considered the commitment to be ethical in dealing with patients and their maintaining acceptable level of their privacy and confidentiality, satisfying patients’ needs in a proper way, one of the major stressors in the nurse’s daily duties.”

“internists’ experiences with ethical dilemmas and supplemented with concerns described by nurses and ethicists in survey research (DuVal et al. 2004; Cheon et al. 2015; Kesselheim et al. 2010; Ulrich et al. 2010).”

“Abundant ethical conflicts are also related to situations in which nurses can’t protect patients’ rights or do their best for a patient, where the autonomy and privacy of the patient is affected, the wishes of the patient are not respected or informing patients and relatives is insufficient.(4,16,19,20) According to n…”

“Today’s healthcare environment has made it difficult for nurses and other healthcare workers to practise with integrity amid the complex moral choices and pressures they confront.(1) New technology, various and increasing demands, limited resources and conflicting values create continuous ethical issues.”

“These ethical challenges coincide with increasing moral distress reports among healthcare providers (Ulrich, Hamric, & Grady, 2010) and a relatively high percentage (46”

“…several factors such as policies and expectations of the institutions where they work, feeling of mastery of the medical profession, stressful environment, patient complex conditions, and the communication with patients that instead of following the rules, they listen to their inner voice [43, 44].”

“Furthermore, some studies have reported that nurses’ different backgrounds, including age, gender, education level, knowledge of ethics, or experience as a nurse may impact their individual ability to recognize ethical issues in their clinical areas.(8,10,13) When providing ethics education to nurses, dealing with fre…”

“For some time, research confirmed that nurses experience moral distress (MD) in their daily work and that this became a major problem for the nursing profession.(3,4,8,9) The problem seems to affect nursing in all healthcare systems.”

“All members of the healthcare team, including nurses, can be affected by ethical decision making, which can impact patient care.(9) In one study that examined medical residents, less than half of the questions asked by patients regarding their procedures were correctly answered by the residents performing the procedur…”

“For example, evidence [34, 35] indicates that understaffing may force nurses to abandon opportunities to provide good nursing care to their patients [18].”

“6,11 HCWs handle ethical dilemmas daily, 61 with studies indicating that moral injury levels among them are comparable to those observed in soldiers deployed in combat zones, 62 reaching up to 69% during the COVID-19 crisis.”

“Prior authors have theorized that nurses, internationally, are equipped to recognize the ethical implications of high-risk clinical situations, but generally fail to recognize the ethical implications of routine nursing actions (Austin, 2007; Krautscheid, 2015; Truog et al., 2015; Ulrich et al., 2010; Zizzo et al., 20…”

“However, because of sociopolitical factors, public health services in rural communities are still faced with dire shortages of resources which increase moral distress among healthcare professionals (Ulrich et al. 2010).”

“The distribution of the items regarding the relationship of nurses with each of these factors is as follows: patients (2, 6, 11, 19), colleagues (1, 10, 18, 23), managers (3, 7, 12, 15, 20, 24), physicians (5, 9, 14, 17, 22, 26), and hospital (4, 8, 13, 16, 21, 25).”

“There is no doubt that healthcare professionals are the pillars of any nation’s health sector because they are the ones who make this sector successful and thrive [1].”

“Examples of stressful situations may be found in ethical frontier zones of medicine [14].”

“Nurses are often faced with everyday ethical decisions in nursing practice that may seem insignificant but which may be stressful for nurses, as they must face the question of what is right and what is wrong (15).”

“Two studies have found that questions concerning autonomy and informed consent to treatment are common and stressful ethical issues faced by nurses in everyday practice.(3,4) Physical restraints are frequently used in the care of older people(5) for a variety of purposes, such as decreasing the risk of falls and injur…”

“In professional healthcare practices, identifying the attitudes and behaviors of surgical physicians and nurses on ethical sensitivity, which is one of the significant components of qualified treatment and care, can contribute to taking the necessary precautions by identifying the deficiencies and errors in this regar…”

“Nurses working in any health-care setting are obligated to support patient decision making when their patients are facing ethical problems and must have the knowledge base to advocate for their patients in facing these ethical dilemmas (Ulrich et al., 2010).”

“Some of the factors leading to greater complexity in the daily care environment include reduced staffing, the increased number of patients with greater and more challenging needs, the need to simultaneously maintain high- quality care while minimising care costs [4,15], that populations are getting older and patients…”

“Ulrich et al.(1) stated that (a) protecting patient rights, (b) autonomy and informed consent to treatment, (c) staffing patterns negatively affecting work, (d) advanced care planning, and (e) surrogate decision making comprise the most frequent causes of moral distress for registered nurses (RNs).”

“factors that contribute to inequities in access to healthcare providers and services.(4) This situation in rural healthcare is mirrored by other developed countries such as the United States and Australia.”

“Health professionals especially nurses face ethical challenges in their daily practice as they are required to provide autonomous and collaborative care to individuals of all ages, while adhering to the ethical principles [3,4].”

“In home care, community nurses often work alone and therefore often face ethical issues or ethical dilemmas by themselves.(9,18,19) While different terms are used to denote moral problems, for example, “moral issues” or “moral conflict,” moral problems are most frequently referred to as “ethical dilemmas” or “moral di…”

“At the same time, previous studies have reported serious challenges in collegial support in professional ethics.(1,6,10,12) The collegial values were also challenged due to the current prevalence of individuality at work.”

“A considerable number of nurses face ethical challenges in their everyday practice (5,6).”

“This understanding would help to alleviate nurses’ concerns, thereby maintaining the workforce and improving care quality and patient safety.(14,17) Phenomenology is appropriate for in-depth study of phenomena that needs to explore and interpret.”

“Part II: This part questioned about participants’ experiences (whether they have experienced ethical issues since they became nurse managers and if so, how often), areas of management where ethical issues were encountered (five pre-identified areas), and scoring of the importance of 11 pre-identified ethical issues wh…”

“Interventions are increasingly used in health care to relieve the moral distress experienced by nurses (Epstein et al., 2019; Moss et al., 2016; Perni, 2017; Ulrich et al., 2010).”

“This situation is aggravated when organisational cultures are self-protective, rules based, unsupportive or unable to change, leading to a sense of powerlessness and little capacity among nurses to influence issues, particularly those that create ethical dilemmas (Atabay, Çangarli, & Penbek, 2015; Ulrich et al., 2010).”

“Autonomy is a foremost ethical principle in health-care and a core principle in ethical decision-making in palliative and end-of-life care [13–16].”

“Aiming at ensuring that a common concept of ‘ethical issue’ was considered by participants, the following definition was reported in the questionnaire: ‘An ethical issue or problem occurs every time a profound moral question of “rightness” or “wrongness” underlies professional decision-making and the beneficent care o…”

“Consistent with previous research (6, 25, 26), the pres - ent study indicates ethically challenging situations to be common in nursing.”

“There are also common and everyday ethical issues related to nursing [6].”

“Practicing nursing with integrity amid the complex moral choices and pressures that nurses confront on a daily basis is challenging [3].”

“In fact, Ulrich et al. (2010) reported that more than a third of their nurse respondents cited staffing concerns, among other issues, as a frequent ethical issue that negatively affected their ability to care for their patients.”

“While many studies have examined ethical issues particular to specific practice areas of nursing, Ulrich et al. (2010) were among the first to conduct a large regional survey of all nurses within four states from a major regional census area in the USA.”

“Best care includes promoting their health, wellbeing, and safety at individual, group, community, and global levels (Interprofessional Education Collaborative, 2016; Wilhelmsson et al., 2012; World Health Organization, 2010.).”

“…international nurse ethics experts recognize the urgent need to develop strategies that more effectively address practice concerns in an effort to retain a qualified workforce (Goethals, Gastmans, & Dierckx de Casterle, 2010; Suhonen, R., Stolt, Virtanen, & Leino-Kilpi, 2011; Ulrich et al., 2010).”

“The last two general themes we found in the dilemma discussions were nurses’ rights versus patients’ rights (half of the dilemmas) and conflict or competence concerns with other health professionals (over one-quarter of the dilemmas); these also have been found in previous research.(4,5,11) Many of the ethical dilemma…”