A Challenging Situation I Encountered in a Clinical Setting With a Patients Family
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Expert nurses' coping strategies in ethically challenging situations: a qualitative study
BMC Nursing volume twenty, Commodity number:183 (2021) Cite this article
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Background
Nurses frequently meet ethically challenging situations in everyday practise. In these situations, nurses often know an appropriate course of activeness to take simply are unable to practise then. Many studies take examined the ethically challenging situations faced by nurses, merely how nurses cope with these situations is not well understood. Therefore, this study aims to explore the coping strategies used or adopted in ethically challenging situations by expert nurses in Southward Korea.
Methods
Participants were recruited via purposive sampling. Small grouping interviews were conducted with 26 expert registered nurses in a general infirmary in Due south Korea. The data were analyzed using Giorgi's descriptive phenomenological method.
Results
The essential theme of nurses' experience of coping with ethically challenging situations was "being true-blue to the nature of caring." This essential theme comprised 3 themes: self-monitoring of ethical insensitivity, maintaining honesty, and actively acting as an advocate.
Conclusions
The findings of this study suggest that the coping strategies of expert nurses are more often than not consistent with the attributes of upstanding competence as previously defined in healthcare, and expert nurses can address ethically challenging situations in an constructive and ethical manner by faithfully adhering to the spirit of caring. System-wide early on counseling and interventions should be considered for nurses who have experienced ethical difficulties.
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Background
Ethically challenging situations that nurses encounter in everyday practise are usually situations in which they know an appropriate form of action to take but do non practise so [1]. Sometimes, nurses may have difficulty in recognizing the correct course of action. Historically, the medical field has lacked a clear definition of an ethically challenging situation in nursing. However, studies within the terminal decade take explored the ethically challenging situations that registered nurses' experience in nursing practice. For example, nurses in the emergency section reported that ethically challenging situations involve being close to the suffering or death of people, being unsure how to express their feelings, having a heavy responsibility, and working in an open up infinite with little privacy for their work with patients [two]. In add-on, nurses providing childhood cancer intendance in Sweden were often concerned most infringing on patients' autonomy, deciding on the appropriate treatment level, and dealing with conflicting perspectives within health professional teams [3].
What nurses require is the upstanding competence to cope with such ethically challenging situations. Upstanding competence can exist defined in terms of individuals' graphic symbol strength (proficient grapheme traits), upstanding awareness (ethical perception), moral judgment skills, and willingness to do the right thing [iv]. Ethical competence depends on the ability to find ethically challenging situations, consider various courses of action, and implement them [1]. Consequently, ethical competence results in positive outcomes for the patient and reduces nurses' moral distress [four], and exploring how nurses cope with ethically challenging situations could improve agreement of nurses' ethical competence.
Numerous studies worldwide have examined ethically challenging situations among nurses in clinical settings. Rathert et al. [five] found that more than half of the 290 nursing staff surveyed in acute care hospitals in the Usa experienced upstanding dilemmas and conflicts frequently (i.e., several times a month to daily). Healthcare professionals in Sweden, including nurses, described three themes of ethically hard situations: a sense of powerlessness in managing the complex emotional needs of patients and relatives, providing unequal care, and dubiety over who is the primary intendance decision-maker [6]. A written report in South korea found that conflicts between nurses and physicians or other nurses were the almost frequently encountered ethically challenging situations across hospital departments [7]. Ethically challenging situations can lead to moral distress in nurses [5, 8, 9], which tin can, in plow, directly harm patients besides every bit nurses' personal and professional lives [ten]. Therefore, information technology is crucial for nurses to cope effectively with ethically challenging situations.
In reviewing the literature, the authors found a few studies [8, nine, 11, 12] that reported on nurses' coping strategies for dealing with ethically challenging situations. For instance, nurses in a hemodialysis center tried to discuss ethical concerns with physicians just largely failed in doing so, causing them to continually feel uncertain and act against their conscience [11]. Oncology nurses mainly remained silent about upstanding concerns, which shaped a civilization of avoidance in conversations on the prognosis and stop-of-life treatment with patients, families, and physicians [12]. The literature review of coping strategies [9] suggested that nurses use various coping resources, which can be positive when they lead to dialogue and reflection or negative when they cause the professional person to have and conform to the context, feel hard ethical situations alone without the support of colleagues or the institution, or become prone to a feeling of moral distress. These previous studies contribute to our understanding of how nurses deal with ethically challenging situations. Nevertheless, 3 of the previous studies [eight, 11, 12] narrowly focused on nurses' coping strategies in special units such every bit hemodialysis or oncology and did not explore the strategies used in general units, and ii studies [8, 9] reported coping strategies for moral distress but did non focus on the ethically challenging situations themselves. Overall, the previous studies did not fully explore how nurses deal with ethically challenging situations in nursing practice. In the electric current study, the authors were interested in skillful nurses' ways of coping because the nurses have abundant feel in dealing with ethically challenging situations. Therefore, this study aims to explore the experiences of expert nurses with regards to coping strategies used or adopted in ethically challenging situations in Due south Korea.
Methods
Blueprint
This study used a descriptive phenomenological research method, equally suggested by Giorgi [13], which is suited for describing an private'due south perspective on their feel.
Study setting
The authors selected a full general hospital located in the capital metropolis of Republic of korea for this written report because it is known as the first and best infirmary with a systematic career evaluation system for nurses. The career evaluation system of this full general infirmary assesses and develops the careers of nurses according to four stages: 1) a nurse complies with nursing standards and performs nursing tasks without difficulty, two) a nurse adjusts nursing goals and priorities and plays the role of a preceptor, 3) a nurse is an good who can individualize and manage the nursing needs of a variety of situations, and 4) a nurse is a head nurse or a professional clinical nurse who is capable of being a role model for nurses [14].
Participants
To recruit good nurses in clinical settings through purposive sampling, nursing team managers or unit managers were asked to recommend expert nurses whose expertise was determined using the career evaluation system. In Republic of korea, nursing team managers or unit managers, including head nurses, spend more fourth dimension doing administrative work than providing directly nursing treat patients. Therefore, the authors recruited skillful nurses who directly care for patients in their practice, and also tried to recruit nurses working in a variety of wards to gain the broadest perspective on the ethically challenging situations nurses face. Recommended expert nurses were invited to this study, and 26 registered nurses participated voluntarily.
Data collection
All data were collected through six small group interviews, and each group interview took place twice. Each group consisted of four to 5 participants, and the participants in each group remained unchanged until the end of the information collection. The authors chose the minor group interview because it helps to "create a natural communicative context for telling stories from practice, assuasive peers to talk to 1 another as they unremarkably talk" in a phenomenological study ([fifteen], p.109). The participants of this written report did not have conflict with or contradict each other but empathized with each other in the group interview. The authors informed each nurse of the chief interview question, which was "How did you cope with ethically challenging situations you experienced while working as a nurse?" via email or phone 1 calendar week before the grouping interview. The interview location was a hospital counseling room or a café near the infirmary.
At the beginning of the first interview, participants completed a questionnaire asking about their general characteristics, such as their historic period, sex, chore championship, educational background, and work feel. The interview began with the question: "How did you lot bargain with ethically challenging situations while working?" Then, the authors asked open-ended questions such every bit, "Delight tell me what you experienced while dealing with ethically challenging situations."
Ane to 2 weeks afterwards the first interview, the second interview was conducted. During the second interview, the authors asked participants boosted questions about the first interview that needed further clarification. Each interview was recorded with the consent of the participants and lasted for two–2.5 h. After interviewing the 26 participants a second time, no new themes were identified indicating information saturation had been accomplished, and no additional participants were recruited. The interviews were conducted in Korean, and the information analysis and clarification of results were in Korean. Then, ane of the authors wrote the manuscript in English.
Ethical considerations
The Institutional Review Board of the infirmary bioethics committee approved this written report. Participants were informed of the written report'due south purpose and methods and their right to withdraw participation at whatsoever fourth dimension up until the report was completed. The participants voluntarily signed a written informed consent form. Their privacy and confidentiality were ensured by referring to them in the manuscript by messages rather than their names.
Data analysis
A phenomenological approach [13] was used to translate the content of the text data through the systematic coding and identification of themes. The audio-recorded interview information were transcribed verbatim by the authors (M and O). Giorgi [13] recommended a three-tiered analysis. First, all authors read the interview transcripts repeatedly to grasp the overall meaning of the text. In the 2nd stride, meaningful statements were selected; two authors (K and O) underlined the sentences or phrases considered most relevant for nurses' coping with ethically difficult situations. Third, each meaning unit (i.e., the participants' own words) was transformed into 'phenomenologically psychologically sensitive expressions' as described by Giorgi [13]. More specifically, two authors (1000 and O) summarized the meaning of each sentence using third-person expressions by making a coding listing. All authors met several times to review the list of codings and hash out how to group them into more than abstract themes. Codings were sorted and categorized into sub-themes based on the similarity of meaning, which were then grouped into themes. For example, awareness of human dignity, self-reflection, and ethical questioning while working were conceptualized into a theme of "self-monitoring of ethical insensitivity." We and so grouped the sub-themes into main themes—self-monitoring of ethical insensitivity, maintaining honesty, and actively correcting mistakes—into the essential theme "being faithful to the nature of caring."
Rigor
The study'due south rigor was examined in terms of brownie, dependability, and transferability, equally described by Graneheim and Lundman [16]. For credibility, we, the authors (ane of whom was an expert in qualitative inquiry), discussed the text several times until we all agreed with the manner the data were labeled and sorted. Additionally, the authors showed the results of the analysis to several participants who ensured the results of the study matched what the participants experienced. Regarding dependability, authors held discussions throughout the data analytic process to ensure the option of consistent themes. Finally, to ensure transferability, the authors described the general characteristics of participants and ethical situations in particular for the reader to sympathise the analytic procedure.
Results
All 26 participants were women, and their boilerplate age was 36.seven years (range: 32–44 years). They had been employed in the current infirmary for an boilerplate of 12 years and 1 month (range: 9 years and ix months to 17 years and ten months; Table one). The essential theme of expert nurses' experiences of coping strategies with ethically challenging situations was "being true-blue to the nature of caring." This essential theme, in turn, comprised three themes: self-monitoring of ethical insensitivity, maintaining honesty, and actively interim as an advocate (Table 2).
Theme 1: self-monitoring of upstanding insensitivity
The expert nurses in this study continually and consciously monitored their ethical insensitivity when confronted with ethically challenging situations. Cocky-monitoring of upstanding insensitivity was a cyclical procedure involving three sub-themes: awareness of human nobility, self-reflecting, and upstanding questioning.
Sub-theme 1: sensation of human dignity
Participants were constantly aware of the man dignity of their patients in the face up of ethically challenging situations. This sensation gave participants new insights into their role as a nurse, bringing them a sense of duty in caring for humans.
"A patient (waiting for organ transplants) was whispering, 'If I live, someone is dead, right?'... I was busy, and I had non even thought nearly it. Yes. ... the work of saving someone (through organ transplants) requires someone to take died. It is non a situation that I can ignore using my busyness equally an excuse" (Participant A, 11 years of experience, medical department).
When expert nurses reminded themselves that they were caring for a human, they became worried they might undermine human dignity. In decorated and often complicated clinical situations, nurses frequently used patients' medical diagnosis and room number (due east.k., 'pneumonia, 1203′) instead of patients' names when talking to other nurses and medical staff, which some believed would help to limit their mistakes in nursing do; withal, they also acknowledged that this practice sometimes led nurses to not treating patients with nobility.
Sub-theme 2: self-reflecting
Participants ofttimes remembered and self-reflected on moments in which they encountered ethically challenging situations such every bit when the workload express their opportunities to limited compassion for patients. Moreover, some participants reflected on how nurses lose opportunities to hold a patient'southward hand or speak warmly to patients and their relatives, feeling that they had not done their job every bit nurses in those instances. Some participants reflected on situations where nurses could non talk well-nigh the patient's handling or prognosis (ofttimes on the doctor'south orders). So, they experienced agony in having to observe helplessly from the periphery, mainly when life-saving treatment was hopeless. "It'south clear that this patient volition not exist able to live beyond a few days, but the doctor continues the treatment until the stop, and family members desire to let the patient go comfortably. I think information technology is not in the best interest of the patient or his family if he is made to keep breathing, take loftier doses of drugs, undergo dialysis, and use a ventilator" (Participant Q, 14 years of experience, surgical department).
Sub-theme iii: upstanding questioning
Participants asked themselves who their nursing was for and whether they were taking the right or appropriate actions in their nursing practice. Ethical questioning arose in situations in which participants had to keep a cloak-and-dagger about a cancer diagnosis, apply physical restraints to patients, and provide treat patients with do not resucitate orders (DNRs). For case, some participants questioned whether it was right not to tell patients with cancer the truth of their diagnosis as requested past the family caregivers or to change the position every 2 hours to prevent bedsores of patients who are about to die. "It'south an crumbling society, and at that place are a lot of older people whose families exercise not desire them to know about information technology (their cancer diagnosis). Most of us ensure confidentiality, but is it right to keep it a hole-and-corner because the patient is so old? Family members may surrender treatment because patients are onetime. Caregivers don't let patients determine for themselves about treatment—is this right?"(Participant M, 17 years and 10 months of experience, surgical department).
Theme two: maintaining honesty
All participants in this written report idea that adhering to the standards of nursing was fundamental to honesty. They strove to exist honest by adhering to principles and standards of nursing and internalizing honesty.
Sub-theme 1: adhering to principles and standards of nursing do
Participants realized that adhering to nursing standards and principles was the basis of ethical nursing practice. Many participants considered it unethical for a nurse to non know the principles and standards of nursing practise. They reported that even uncomplicated nursing tasks had to be performed faithfully and transparently in accord with these standards. Examples of these standards were giving medications only every bit prescribed, not fabricating nursing records, and not acting hypocritically to cover up a problem.
"In the by, a patient who was waiting for an organ transplant sometimes asked me to record his status equally worse than it was. He asked me to record that he'southward unconscious … I told the patient that it wasn't possible" (Participant P, 11 years and 3 months of experience, surgical section).
Moreover, participants rejected doctors' unscrupulous orders and lacked tolerance for other colleagues' mistakes. Nurses sometimes encountered conflicts in their relationships with other nurses, doctors, patients, and relatives of patients while adhering to these principles.
Sub-theme 2: internalizing honesty
All participants mentioned that honesty is a virtue for nurses in any ethically challenging situation. Many such situations would go unnoticed by others, even if nurses were dishonest about them. Loftier workloads or situations in which others' actions were difficult to observe straight often presented participants with the opportunity to make questionable choices for convenience rather than for the sake of honesty. However, participants mentioned that they continually strove to internalize a sense of honesty to avert unethical temptations.
"The most important thing is honesty. I had to go gear up for surgery really quickly, just so my collar or something touched my manus. I was agape I'd get in trouble if I told my senior. However, it's wrong to pretend that nothing happened. That's why I always say I should non pretend that I do non know. I also tell other nurses not to do that" (Participant 10, 12 years and three months of experience, operating department).
Theme 3: actively acting every bit an advocate
Sub-theme 1: expressing oneself regarding a treatment given or an erroneous situation
Participants actively participated in rounds with doctors and expressed their opinions on the treatment existence given. Skilful nurses accurately conveyed their opinions with confidence in conversations with doctors. For example, some participants asked the medico whether they had made a DNR determination besides early. They too actively sought out physicians to solve problems (due east.1000., prescription errors). "Even with dyspnea, I said to the md, 'The current situation is not just an ascertainment. The patient is showing Cheyne-Stokes breathing. You should come right away'"(Participant D, seven years and 10 months of experience, medical department).
When nurses and doctors had difficulty communicating, participants would intercede to avert any impairment to the patient and various other ethical and legal problems (due east.g., negligence of duty). Moreover, if fellow nurses or doctors did something wrong, participants mentioned information technology to the medical staff involved and asked them to rectify the mistakes. When participants became team leaders, preceptors, and accuse nurses, they began to more actively check for unethical behavior, telling superiors and clinical professors, too as other nurses, in accelerate about actions that might impairment patient safety to prevent bug from occurring.
"When educating family members to wear gowns ... Now I accept a voice, and I have been working as a responsible nurse since final year. I am trying to exercise as much as I can" (Participant L, 11 years and six months of experience, surgical section).
For situations in which trouble-solving was non possible at the personal level, participants acted at the organizational level by reporting the problem to the head nurse (i.e., the unit manager), and and then collecting and analyzing data on recurring problematic situations and reporting the results to the department of nursing administration.
Sub-theme two: being a mediator
Participants helped in accurately carrying the opinions of the patient and family unit members to the physician during rounds, which helps maintain patients' self-determination in therapy. One participant even asked another participant to append a DNR society until it had been sufficiently explained to patients and their family members.
The participants served as advisors to patients and family members to help them make the right choices. For example, a patient, who wanted to go on her illness a hush-hush, raised the ethical result of whether her mother should know of her medical condition. Afterwards listening to the patient, the participant recognized that the patient was suffering considering of a cleaved relationship with her mother, and thus actively mediated the trouble every bit a patient abet. Another participant reported how a patient had been prescribed a medicine that was convenient for medical staff but financially burdensome to the patient, so she asked the doctor to correct the prescription by explaining the patient'south situation.
"The simply persons who tin can stand up for patients are nurses. We are their spokesmen. When I looked upwardly the child's past and current medical history, the child's father was unemployed. I then found that the price of medicine, fifty-fifty though information technology was insured, was 47,000 won ($46). ... I asked the doctor to prescribe merely the exact dose that was necessary"(Participant Five, 13 years and five months of feel, intensive intendance unit of measurement).
Discussion
This report explored adept nurses' feel of coping with ethically challenging situations to empathise nurses' upstanding competence in nursing do. The findings of this report advise attributes of upstanding competence that are mostly consequent with those of ethical competence every bit it has been previously defined in healthcare [four, 17, eighteen]. Eriksson et al. [17] argued that ethical competence in healthcare must consist of being (virtues), doing (rules and principles), and knowing (critical reflection). The findings of this study explained the characteristics of doing and knowing in greater detail than Eriksson et al. [17]. The expert nurses of this report expressed their "knowing" as they were self-monitoring for ethical insensitivity through cocky-reflection and ethical questioning with an awareness of human nobility. Gallagher [eighteen] defined ethical competence as the possession of ethical knowledge, perception, reflection, and behavior. In this written report, ethical knowledge was involved in the entire process of recognizing, reflecting upon, and acting on ethical issues rather than expressed independently from ethical perception, reflection, and behavior. For example, for a nurse to adhere to the standards of nursing, they must first know the nursing standards.
All participants of this written report also expressed ethical perception as an awareness of human dignity in ethically challenging situations. Gastmans ([19], p.146) proposed that the essence of nursing care is "to provide care in response to the vulnerability of a human being in club to maintain, protect, and promote his or her dignity every bit much as possible." Nurses have an ethical obligation to maintain and respect individuals' dignity and integrity [20]. All participants realized the importance of preserving patients' nobility, which in turn fabricated them continually reflect on what the correct course of activeness was in ethically challenging situations.
Ethical reflection is an essential aspect of ethical competence [17, 18]. Using cocky-reflection and upstanding questioning, all participants in this study habitually monitored their actions and thoughts to avoid ethical insensitivity while working in clinical settings. Ethical insensitivity or numbness is considered to exist a loss of moral sensitivity [21] and is believed to be one of the main ethical issues that nurses face [22]. Nurses may become ethically insensitive when they are too busy with work in clinical settings [twenty, 22]. All the same, the participants in this study engaged in abiding self-reflection to avoid ethical insensitivity. Cocky-awareness has been establish to lead to greater competence in nursing [23]. Moreover, cocky-reflective behavior (e.g., request oneself "What should I do?") was also helpful in making nurses' controlling more than ethical [24]. Nurses should appoint in self-reflective behavior to be more ethically competent, and cocky-reflection could be encouraged through conversation [17] with colleagues or reflexive writing [24].
The expert nurses in this report mentioned the following types of ethical behaviors: adhering to principles and standards of nursing, internalizing honesty, giving i's opinion on a treatment given or an erroneous situation, and beingness a mediator. Nurses have a responsibleness to advocate for patients and their relatives, and are in an excellent position to be aware of the risk factors of ethical problems that may harm patients in clinical settings [25]. The participants could correct mistakes and resolve ethical conflicts by actively expressing their views on patients' care and treatment by adhering to their own moral beliefs. Most importantly, nurses must be given opportunities to vocalization their opinions in ethically challenging situations to advocate for patients' rights to health [26], and they crave resources for dealing with their ethical quandaries [iii]. Therefore, system-level support aimed at enhancing the moral resilience of nurses is necessary [27] for an ethical work environment [28].
Limitations
Qualitative research is never intended to allow for generalization, just it is necessary to obtain a sufficient number of participants to describe a phenomenon comprehensively. In this respect, a limitation of this report is that good nurses working in one general hospital in South Korea, rather than several hospitals, were included in the study. Considering the study was merely conducted in one hospital, despite the first and best hospital with a systematic career evaluation system for nurses in South korea, the written report results may non represent other hospitals in Due south Korea. Some other limitation concerns the selection criteria for expert nurses—we relied on the hospital's evaluation system, which is not nationally standardized; in the time to come, the criteria for defining an skilful nurse demand to exist universally standardized. The authors did not consider the participant's characteristics such every bit historic period or experience when forming the minor interview groups, merely mainly considered the participant'south available hours for interviews. Moreover, this study did non explore the role of the characteristic traits of expert nurses in coping with ethically challenging situations. Therefore, futurity inquiry needs to report coping strategies by considering the moral character of nurses.
Conclusions
The results of this written report suggest that the best way for skillful nurses to cope with ethically challenging situations is to treat patients faithfully according to the spirit of caring. After all, finer coping with ethical problems requires nurses to realize the demand to preserve the dignity of the patient, engage in self-reflection and upstanding questioning, and maintain honesty as much as possible by adhering to the nursing principles and standards and speaking out every bit patient advocates. The results of this study could help nurses cope with the upstanding difficulties they experience. Besides, expert nurses' experience of dealing with ethically challenging situations could help in guiding new nurses and nursing students. Furthermore, system-wide early counselling and interventions should be established for nurses who have experienced upstanding difficulties to ensure ethical nursing practices.
Availability of data and materials
The datasets generated and/or analyzed during the current written report are non publicly available due to the small sample size, but anonymized data are available from the corresponding writer on reasonable request.
Abbreviations
- DNR:
-
Do not resucitate order
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Acknowledgments
The authors are most grateful to the nurses for their participation and would like to thank Editage (world wide web.editage.com) for providing English language editing.
Funding
This research did not receive whatever specific grant from funding agencies in the public, commercial, or non-for-profit sectors.
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Study blueprint: YHK, YK, JHO, KC. Data collection: YK, JHO. Data analysis: YHK, YK, JHO, KC. Manuscript writing: YHK, YK, JHO, KC. Disquisitional revisions for important intellectual content: KC. All authors have read and canonical the manuscript.
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This study was approved by the ethics commission of Asan Medical Center (2015-0035). Written consent was obtained from all participants.
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The authors declare that they have no competing interests.
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Kim, Y.H., Kang, Ya., Ok, J.H. et al. Skillful nurses' coping strategies in ethically challenging situations: a qualitative written report. BMC Nurs twenty, 183 (2021). https://doi.org/ten.1186/s12912-021-00709-w
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Published:
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DOI : https://doi.org/10.1186/s12912-021-00709-westward
Keywords
- Coping behavior
- Ethical competency
- Healthcare ethics
- Medical ethics
- Nursing ethics
- Professional person ethics
Source: https://bmcnurs.biomedcentral.com/articles/10.1186/s12912-021-00709-w
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