Nursing Ethics

In order to achieve the goals of the healthcare system, nursing managers are required to comply with ethical principles in decision-making. In complex and challenging healthcare settings, it is shown that the managers’ mere awareness of ethics does not suffice and managers need to be sensitive toward making ethical decisions.

To explore nursing managers and their sensitivity toward ethical decision-making by analyzing their related experiences.

The current study has been conducted in Iran in 2017 through a qualitative content analysis approach. Nineteen nurse managers were selected purposefully from different hospitals in Tehran. Data were collected using semi-structured, in-depth, face-to-face interviews, and after transcription, they were analyzed according to the Graneheim and Lundman method.

The research was approved by the ethics committee of Tarbiat Modares University, Tehran, Iran. Participants were informed about the purpose of the study and submitted written informed consents regarding their participation. The principle of autonomy, confidentiality, and anonymity was taken into account in data collection.

Fifteen subcategories, three categories (assertiveness, commitment, and insight), and one theme of excellent decision-making were the results of data analysis.

Findings showed that nursing managers’ sensitivity to ethical decision-making allows them to make the best decision by insight, commitment, and assertiveness. Making a morally excellent decision ensures that ethical principles are followed in the healthcare system.

Considering that most managers are committed to making ethical decisions, it is required to develop the scope of their insights even further using a professional management and ethical principles training program. Also, by addressing some of the ethical barriers at personal and organizational levels, the assertiveness in managers can be improved, which in turn can facilitate their ethical decision-making.

Concepts of health have been widely discussed in the philosophy and ethics of medicine. Parallel to these theoretical debates, numerous empirical research projects have focused on subjective concepts of health and shown their significance for individuals and society at various levels. Only a few studies have so far investigated the concepts of health of non-professionals and professionals involved in long-term home care and discussed these empirical perspectives regarding moral responsibilities.

To identify the subjective concepts of the health of non-professionals (care recipients, informal caregivers) and professionals (registered nurses) involved in long-term home care and to discuss them against the background of existing normative guidelines addressing non-professionals and professionals’ responsibilities and rights concerning health.

A qualitative design was chosen to explore subjective concepts of health. Data were collected by semi-structured interviews; content analysis was applied according to Mayring.

Twenty-eight interviews were conducted with non-professionals and professionals in long-term home care arrangements in Northern Germany.

Ethics approval was obtained from the Institutional Review Board at the University Medicine Greifswald (BB123/16).

Non-professionals and professionals consider health as a capability that enables them to participate in social activities and live their own lives according to their preferences. The former regard health particularly as a feeling and an attitude, the latter as the absence of disease with a focus on mental and emotional well-being. Both groups highlight the unsurpassable value of health and the personal responsibility for it.

Normative guidelines applicable to practice in long-term home care discuss responsibilities and rights unevenly and raise several problems regarding non-professionals and professionals’ subjective concepts of health.

Individuals’ concepts of health are relevant for the subsequent interpretation of rights and responsibilities and should, thus, be reflected upon to address health-related needs effectively.

Considering the extensive debate that is currently taking place in Spain regarding euthanasia, it is important to examine the attitude of professionals who perform most of their duties at the bedside of these patients and their families.

The aim of the present study was to present an adaptation and validation of the Euthanasia Attitude Scale and to evaluate its psychometric properties among a sample of nursing students in Spain.

A cross-sectional study design was conducted.

Non-probabilistic sampling was used to recruit 396 Spanish nursing students.

A self-report questionnaire, including socio-demographic data and the Euthanasia Attitude Scale, were used for data collection. The psychometric properties of the Euthanasia Attitude Scale were assessed, including reliability and validity. Fit indices of the overall model were computed.

This study was approved by the Hospital Ethical Committee. Students were informed of the aims and procedures and provided written informed consent prior to data collection.

The factorial solution comprised four domains and the scale demonstrated adequate internal consistency (Cronbach’s alpha = .878). For the exploratory factor analysis, the Kaiser–Meyer–Olkin index of sampling adequacy was .905 and the Bartlett’s Test of Sphericity was 2972.79 (p < .001). The initial factorial solution revealed four factors with eigenvalues of 6.78 for the first factor, 1.90 for the second one, 1.29 for the third, and 1.10 for the fourth factor. Moreover, there was a significant relationship between religiosity and the domains of the Euthanasia Attitude Scale.

This study obtained a Cronbach’s alpha coefficient of .88 which is in consonance with the findings reported by other studies whereby none of the items were removed and the initial structure based on four domains was conserved, with a factorial solution that explains 52.79% of the total variance. The displacement of some items of the domain may be explained by certain religious and/or cultural components as, in accordance with other studies, people with firm religious beliefs are more inclined to refuse euthanasia.

According to the findings of this study, the Euthanasia Attitude Scale is a reliable and valid instrument to measure the attitudes toward euthanasia in a sample of Spanish nursing students. This Spanish adaptation will be valuable in future studies examining the attitude and implication of nurses, understanding that nurses are key figures in the euthanasia debate.

Nursing documentation as a pivotal part of nursing care has many implications for patient care in terms of safety and ethics.

To explore factors influencing nursing documentation from nurses’ perspectives in the Iranian nursing context.

This qualitative study was carried out using a qualitative content analysis of data collected from 2018 to 2019 in two urban areas of Iran. Semi-structured interviews (n = 15), observations, and reviews of patients’ medical files were used for data collection.

This study was conducted in accordance with the ethical principles of research and regulations in terms of confidentiality of data, anonymity, and provision of informed consent.

The main theme of this study was “unsafe documentation.” Two categories, “types of errors in reporting” and “reasons of errors in reporting,” and 12 subcategories were developed indicating factors influencing nursing documentation in the Iranian nursing context.

In general, individual, organizational, and national factors affected nursing documentation in Iran. In this respect, hiring more nurses, application of reforms in the healthcare management structure, devising appropriate regulations regarding division of labor, constant education of healthcare staff, establishment of clinical governance, improvement of interpersonal relationships, development of hardware and software techniques for documentation, and provision of support should be done to improve the quality of nursing documentation. The above-mentioned suggestions can help nurses with a safe, ethical, lawful, and reliable documentation in nursing practice.

Nursing students spend approximately half of their time in clinical practice. It is important that clinical supervisors understand nursing students’ path of learning and can support their growth and development during the different and multifaceted learning situations offered in the clinical-practice period.

Based on nursing students’ perspective and rooted in the didactics of caring science, to examine how a learning and constructive caring relationship between nursing students and supervisors in clinical practice can be formed.

Qualitative and quantitative concurrent triangulation design of mixed methods.

Focus group interviews with Finnish nursing students (n = 21) in the qualitative part of the study. In the quantitative part, a closed questionnaire with closed answers was analysed using descriptive statistics. The analysis process was conducted using inductive content analysis.

Ethical issues were considered throughout the research process according to ethical principles and scientific guidelines. Informed consent was obtained from the informants, confidentiality regarding the data material was guaranteed and quotations were anonymized.

A caring relationship between nursing students and supervisors is based on mutual respect, the ethos of responsibility, motivation, willingness and professionalism. Dignity and a caring ethical approach, where nursing students feel they belong, are recognized, seen and heard enables learning and professional development. It is also significant that the supervisor’s actions and reflections are ethically defensible, equal and protect nursing students from suffering and various power relationships in clinical practice.

A good cooperative relationship and shared responsibility between the nurse education institution, which offers theory and prepares nursing students for the encounter with clinical practice and the healthcare organizations is crucial for enabling a caring relationship in clinical supervision.

Currently a variety of novel scenarios have appeared within nursing practice such as confidentiality of a patient victim of abuse, justice in insolvent patients, poorly informed consent delivery, non-satisfactory medicine outputs, or the possibility to reject a recommended treatment. These scenarios presuppose skills that are not usually acquired during the degree. Thus, the implementation of teaching approaches that promote the acquisition of these skills in the nursing curriculum is increasingly relevant.

The article analyzes an academic model which integrates in the curriculum a series of specific theoretical concepts together with practical skills to acquire the basic ethic assessment competency.

The project includes designing two subjects, General Anthropology and Ethics-Bioethics, with an applied approach in the nursing curriculum. The sequential structure of the curriculum in both subjects is constituted by three learning domains (theoretical, practical, and communicative) with different educational strategies.

No significant ethical considerations as this is a discussion paper.

The model was structured from the anthropology’s concepts and decision-making process, applied to real situations. The structure of the three domains theoretical–practical–communicative is present in each session.

It is observed that theoretical domain fosters the capacity for critical analysis and subsequent ability to judge diverse situations. The practical domain reflected two significant difficulties: students’ resistance to internalizing moral problems and the tendency to superficial criticism. The communicative domain has frequently shown that the conflicting points are in the principles to be applied.

We conclude that this design achieves its objectives and may provide future nursing professionals with ethical competences especially useful in healthcare practice. The three domains of the presented scheme are associated with the same process used in decision making at individual levels, where the exercise of clinical prudence acquires particular relevance.

Nursing students form a professional identity from their core values, role models, and past experiences, and these factors contribute to the development of their professional identity. The hidden curriculum, a set of ethics and values learned within a clinical setting, may be part of developing a professional identity. Nursing students will develop a professional identity throughout school; however, their identity might be challenged as they attempt to balance their core values with behaviors learned through the hidden curriculum. The purpose of this project was to educate students on the hidden curriculum in the development of their professional identity.

A sample of 112 senior nursing students was recruited from a northeastern university in the United States for this study. Pre–post survey design was used, and an educational session was administered prior to the post-survey. Descriptive statistics and a valid percentage were used to describe the data within the surveys.

Study was approved by the author’s University Institutional Review Board.

A significant finding was for advocacy as students would speak up if witnessing inappropriate behavior toward patients or families with a mean score increase from 2.50 (pre-survey) to 1.45 (post-survey). Also, over 95% (n = 106) found the educational session beneficial as they learned they had the ability to advocate and speak up for their patients.

Students were able to use their core values and advocate for their patients and families which allows for safer patient care.

Nurses experience moral distress when they cannot do what they believe is right or when they must do what they believe is wrong. Given the limited mechanisms for managing ethical issues for nurses in Japan, an Online Ethics Consultation on mental health (OEC) was established open to anyone seeking anonymous consultation on mental health practice.

To report the establishment of the Online Ethics Consultation and describe and evaluate its effectiveness.

The research was conducted in accordance with the Declaration of Helsinki.

This evaluation describes the outcomes of 5 years of operation of the Online Ethics Consultation on mental health in Japan

The Online Ethics Consultation received 12 emails requesting consultation. Consultees included mental health nurses, psychiatrists, and service users.

The most common questions directed to the service were about seclusion and physical restraint. Response time from receipt of email to sending a reply was between 1 and 14 days. Despite the disappointing number of consultations, feedback has been positive.

The Online Ethics Consultation was established to assist morally sensitive nurses in resolving their ethical problems through provision of unbiased and encouraging advice. Mental health care in Japan has been less than ideal: long-term social hospitalization, seclusion, and restraint are common practices that often lead to moral distress in nurses and the questions received reflected this. The head of the Online Ethics Consultation sent a supportive, facilitative response summarizing the opinions of several consultants.

This study provides key information for the establishment of an online ethics resource the adoption of which has the potential to improve the experience of nurses, allied health and clients of mental health services. This paper has implications for services concerned with improving patient care, managing nurses’ moral distress, building ethics into decision-making.

Coercion can cause harm to both the patient and the patient’s family. Few studies have examined how the coercive treatment of a close relative might affect young next-of-kin.

We aimed to investigate the views and experiences of health professionals being responsible for supporting young next-of-kin to patients in mental health care (children-responsible staff) in relation to the needs of these young next-of-kin in coercive situations and to identify ethical challenges.

We conducted a qualitative study based on semistructured, focus group interviews and an individual interview.

We held three focus group interviews with six to seven children-responsible staff in each group (a total of 20 participants) and one individual interview with a family therapist. The participants were recruited from three hospital trusts in the eastern part of Norway.

The study was approved by the National Data Protection Official for Research and based on informed consent and confidentiality.

Coercion was not a theme among the participants in relation to their work with young next-of-kin, and there was much uncertainty related to whether these young people need special support to deal with the coercive treatment of their close relative. Despite the uncertainty, the study indicated a need for more information and emotional support among the youth.

Few studies have addressed the potential impact of coercive treatment of a close family member on young next-of-kin. The findings were consistent with existing research but highlighted disagreement and uncertainty among the children-responsible staff about to what extent the young next-of-kin should visit and whether they should enter the ward unit or not. We identified ethical challenges for the children-responsible staff related to the principle of not inflicting harm (nonmaleficence).

From the perspective of children-responsible staff, it appears that the coercive treatment of a close family member entails a need for extra support of young relatives both in relation to information and the facilitation of visits, but more systematic knowledge about these issues is needed.

Neonatologists, legal experts and ethicists extensively discuss the ethical challenges of decision-making when a child is born at the limit of viability. The voices of parents are less heard in this discussion. In Norway, parents are actively shielded from the burden of decision-making responsibility. In an era of increasing patient autonomy, is this position still defendable?

In this article, we discuss the role of parents in neonatal decision-making, based on the following research question: Should parents decide whether to provide lifesaving treatment when their child is born at the limit of viability?

We conducted eight interviews with 12 parents, 4 individuals and 4 couples, all having experienced prenatal counselling at the limit of viability. The interviews took place at different university locations in Norway in the years 2014–2018.

All study participants gave their written informed consent. The Regional Committee for Medical Research Ethics approved the study.

We identified six main themes in parents’ responses to the research question. Parents (1) experienced an emotional turmoil confronted with birth at the border of viability, (2) emphasized the importance of being involved in decision-making, (3) described and reflected on the need to balance the parental instinct of saving, (4) were concerned about the dilemmas involved in protecting the family, (5) were worried about the burden of overwhelming responsibility and (6) called for guideline relief.

The perceived parental instinct of saving the life of their child makes it hard for parents to step away from a call for ‘everything to be done’. Involvement of an interprofessional periviability team drawing on the experiences and viewpoints of nurses and neonatologists in decision-making is needed to protect both infants and parents against undue parental push for treatment and enable parents to make good decisions regarding their child.

The phenomenon of ‘moral distress’ has continued to be a popular topic for nursing research. However, much of the scholarship has lacked conceptual clarity, and there is debate about what it means to experience moral distress. Moral distress remains an obscure concept to many clinical nurses, especially those outside of North America, and there is a lack of empirical research regarding its impact on nurses in the United Kingdom and its relevance to clinical practice.

To explore the concept of moral distress in nursing both empirically and conceptually.

Feminist interpretive phenomenology was used to explore and analyse the experiences of critical care nurses at two acute care trauma hospitals in the United Kingdom. Empirical data were analysed using Van Manen’s six steps for data analysis.

The study was approved locally by the university ethics review committee and nationally by the Health Research Authority in the United Kingdom.

The empirical findings suggest that psychological distress can occur in response to a variety of moral events. The moral events identified as causing psychological distress in the participants’ narratives were moral tension, moral uncertainty, moral constraint, moral conflict and moral dilemmas.

We suggest a new definition of moral distress which captures this broader range of moral events as legitimate causes of distress. We also suggest that moral distress can be sub-categroised according to the source of distress, for example, ‘moral-uncertainty distress’. We argue that this could aid in the development of interventions which attempt to address and mitigate moral distress.

The empirical findings support the notion that narrow conceptions of moral distress fail to capture the real-life experiences of this group of critical care nurses. If these experiences resonate with other nurses and healthcare professionals, then it is likely that the definition needs to be broadened to recognise these experiences as ‘moral distress’.

In this article, the sources and features of moral distress as experienced by acute psychiatric care nurses are explored.

A qualitative design with 16 individual in-depth interviews was chosen. Braun and Clarke’s six analytic phases were used.

Approval was obtained from the Norwegian Social Science Data Services. Participation was confidential and voluntary.

Based on findings, a somewhat wider definition of moral distress is introduced where nurses experiencing being morally constrained, facing moral dilemmas or moral doubt are included. Coercive administration of medicines, coercion that might be avoided and resistance to the use of coercion are all morally stressful situations. Insufficient resources, mentally poorer patients and quicker discharges lead to superficial treatment. Few staff on evening shifts/weekends make nurses worry when follow-up of the most ill patients, often suicidal, in need of seclusion or with heightened risk of violence, must be done by untrained personnel. Provision of good care when exposed to violence is morally challenging. Feelings of inadequacy, being squeezed between ideals and clinical reality, and failing the patients create moral distress. Moral distress causes bad conscience and feelings of guilt, frustration, anger, sadness, inadequacy, mental tiredness, emotional numbness and being fragmented. Others feel emotionally ‘flat’, cold and empty, and develop high blood pressure and problems sleeping. Even so, some nurses find that moral stress hones their ethical awareness.

Moral distress in acute psychiatric care may be caused by multiple reasons and cause a variety of reactions. Multifaceted ethical dilemmas, incompatible demands and proximity to patients’ suffering make nurses exposed to moral distress. Moral distress may lead to reduced quality care, which again may lead to bad conscience and cause moral distress. It is particularly problematic if moral distress results in nurses distancing and disconnecting themselves from the patients and their inner selves.

Spirituality has always been present in the history of nursing and continues to be a topic of nursing interest. Spirituality has ancient roots. The term ‘spirituality’ is interpreted as spirit and is translated as breath and soul, whereas spirituality (immateriality) is spiritual nature. Historically, the term spirituality is associated with the term religiosity, a definition that persists today, and often the two terms are used interchangeably. In the healthcare context, the construct is still.

To clarify the concept of spirituality in nursing.

In this article spirituality was explored using Rodgers' evolutionary and inductive method of concept analysis.

For this analysis, a sample of 71 articles published in English, from 2008 to 2018 from PubMed/Medline, CINAHL Plus with full text, PsycINFO, SciELO databases were retrieved. It was also accomplished an empirical search of dictionaries and e-books.

This study was conducted according to good scientific practice.

It emerged that “spirituality” is a dynamic process and has a range of attributes. The cultural dimensions, the religious and spiritual traditions, the ethnic diversity and the influence of the historical and social contexts represent the societal and historical conditions ingrained in the Western thought that influence the emergence of spirituality as a concept. Antecedents, attributes and onsequences appeared to inform and strengthen one another over time. Spirituality is a significant concept for the discipline of nursing with profound consequences for caring patients and for work organizations.

Non-technical skills are cognitive and interpersonal skills underpinning technical proficiency. Ethical values and respect for human dignity make operating room nurses responsible for nursing decisions that are clinically and technically sound and morally appropriate.

To learn what ethical issues operating room nurses perceive as important regarding non-technical skills.

Qualitative individual in-depth interviews were conducted. The interviews were analysed using Braun and Clarke’s six phases for thematic analysis.

Eleven experienced perioperative/operating room nurses working in an operating unit at a Norwegian university hospital.

Approval was given by The Norwegian Social Science Data Service in care of the hospital’s Data Protection Officer.

Three main themes were found: respect and care for the patient, making the patient feel safe, and respect within the perioperative team. These features or themes, which incorporate collaboration and communication, are closely connected to patient safety.

Defending the patient’s dignity is part of caring for and respecting the patient. The manner in which the operating room team collaborates is important for the patient to feel safe and secure. Poor teamwork may have dire consequences. Reciprocal respect within the team includes respect for each other’s tasks and responsibilities and to talk to one another in a friendly manner.

Being respectful and contributing to a caring atmosphere are central ethical skills in the operating room. To patients, harmonious teamwork translates into a feeling of safety and being cared for. The nurses see respect and patient safety, and respect and reciprocal politeness among the members of the perioperative team as central ethical non-technical skills. Lack of respect influences the team negatively and is detrimental for patient safety. Good communication is an important safety measure during surgery and creates a feeling of good ‘flow’ within the operating room team.