Nursing Archives - Page 3 of 5 - Protection of Conscience Project Library

Moral Distress, Moral Residue, and the Crescendo Effect

Elizabeth Gingell Epstein, Ann Baile Hamric

Extract
It is doubtful that moral distress can ever be eradicated from healthcare settings. As increasing evidence accumulates to support the damaging effects associated with this phenomenon over time, however, interventions to decrease moral distress and moral residue become more urgently -needed. The crescendo effect model focuses attention on moral distress and moral residue and the relationships between them. . . . Both providers and healthcare systems need to acknowledge the repetitive nature of morally distressing events, such as prolonged aggressive treatment at the EOL, that occur in clinical settings. The crescendo effect highlights the crushing blow to professional integrity that nurses, physicians, and other disciplines have to manage on a daily basis in settings where moral distress goes unrecognized and unaddressed. It is not appropriate to expect highly skilled, dedicated, and caring healthcare professionals to be repeatedly exposed to morally distressing situations when they have little power to change the system and little acknowledgment of these experiences as personally damaging or career compromising. As evidence for the crescendo effect and its consequences accumulates, healthcare professionals, insurers, patients, and healthcare systems must not assume that damaged moral integrity is an acceptable, natural consequence that must be borne by healthcare providers.

Epstein EG, Hamric AB. Moral Distress, Moral Residue, and the Crescendo Effect. J. Clin. Ethics. 2009 Winter;20(4):330-342

Abortion and the politicisation of conscience

Megan-Jane Johnstone

Extract
In formulating a response to the abortion issue, the nursing profession needs to be careful not to lose sight of its moral obligation to ensure that women receive the care they require. Nurses also need to be wary of the politicisation of conscience and the corrupting influence this can have on authentic debate about complex moral issues.

Johnstone M-J. Abortion and the politicisation of conscience. Aust Nurs J. 2008 Dec;16(6):21.

Stress of conscience and perceptions of conscience in relation to burnout among care-providers in older people

Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin

Abstract
Aims. The aim was to study the relationship between conscience and burnout among care-providers in older care, exploring the relationship between stress of conscience and burnout, and between perceptions of conscience and burnout.

Background. Everyday work in healthcare presents situations that influence care-providers’ conscience. How care-providers perceive conscience has been shown to be related to stress of conscience (stress related to troubled conscience), and in county council care, an association between stress of conscience and burnout has been found.

Method. A questionnaire study was conducted in municipal housing for older people. A total of 166 care-providers were approached, of which 146 (50 registered nurses and 96 nurses’ aides/enrolled nurses) completed a questionnaire folder containing the stress of conscience questionnaire, the perceptions of conscience questionnaire and the maslach burnout inventory. Multivariate canonical correlation analysis was used to explore relationships.

Result. The relationship between stress of conscience and burnout indicates that experiences of shortcomings and of being exposed to contradictory demands are strongly related to burnout (primarily to emotional exhaustion). The relationship between perceptions of conscience and burnout indicates that a deadened conscience is strongly related to burnout.

Conclusion. Conscience seems to be of importance in relation to burnout, and suppressing conscience may result in a profound loss of wholeness, integrity and harmony in the self.

Relevance to clinical practice. The results from our study could be used to raise awareness of the importance of conscience in care.

Juthberg C, Eriksson S, Norberg A, Sundin K. Stress of conscience and perceptions of conscience in relation to burnout among care-providers in older people. J Clin Nurs. 2008 Jun 10;17(14):1897-1906.

(Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care

Helen Kohlen

Extract
In this work the institutionalisation of Hospital Ethics Committees in the USA and in Germany will be analysed by focussing on nurses’ participation and the representation of caring issues. Therefore, questions about the design of Hospital Ethics Committees and how their practices really look like, will be raised. The central question is, how the traditional care ethos of the helping professions in medicine and nursing can find its place in discussions of these committees while hospitals have increasingly been organised along economic criteria.

. . . .My observations and interviews in the field work show that care practices in the tradition of Hippocratic Medicine are no longer self-evident for the helping professions. Physicians and nurses do rather struggle for a care ethos especially with regard to end-of- life questions and regulations of tube-feeding. The “cases” for ethics consultation brought into the committees by physicians and nurses did not rarely emerge as social problems and as a lack of professional competence. The problems appeared to be solvable by translating them into a language of principles and making the process manageable. These principle-based discussions in the practical arena of the hospital resemble discourse practices embedded within the larger bioethical debates in the political arena. Technical procedures given by management and administration do fit into the use of abstract principles and contribute to a language that limits the possibilities to think – what is at stake for patients – in terms of caring relations rather than thinking in terms of rules, regulations and control.

Kohlen H. (Thesis) Hospital Ethics Committees in the USA and in Germany Bioethics qua Practice, Nurses’ Participation and the Issues of Care. Gotfried Wilhelm Leibniz University, Hanover, Germany. 2008 Apr 02.

Nurses’ involvement in the care of patients requesting euthanasia: a review of the literature

Nele Del Bal, Chris Gastmans, Bernadette Dierckx de Casterlé

Abstract
OBJECTIVES: The aim of this paper is to thoroughly examine the involvement and experiences of nurses in the care of mentally competent, adult patients requesting euthanasia (i.e. administration of lethal drugs by someone other than the person concerned with the explicit intention of ending a patient’s life, at the latter’s explicit request) by means of a literature review. . .
CONCLUSIONS: Nurses can make a significant contribution to the quality of care by assisting and counseling patients and their families, physicians, and their nursing colleagues in a professional manner, even in countries where euthanasia is not legal. However, research on nurses’ involvement in euthanasia has methodological and terminological problems,leading to our recommendation for more carefully designed qualitative studies that explore in-depth the experiences of nurses in caring for patients requesting euthanasia.

Bal ND, Gastmans C, de Casterlé BD. Nurses’ involvement in the care of patients requesting euthanasia: a review of the literature. Int J Nurs Studies. 2008;45(4):626-644.

Perceptions of conscience in relation to stress of conscience

Christina Juthberg, Sture Eriksson, Astrid Norberg, Karin Sundin

Abstract
Every day situations arising in health care contain ethical issues influencing care providers’ conscience. How and to what extent conscience is influenced may differ according to how conscience is perceived. This study aimed to explore the relationship between perceptions of conscience and stress of conscience among care providers working in municipal housing for elderly people. A total of 166 care providers were approached, of which 146 (50 registered nurses and 96 nurses’ aides/enrolled nurses) completed a questionnaire containing the Perceptions of Conscience Questionnaire and the Stress of Conscience Questionnaire. A multivariate canonical correlation analysis was conducted. The first two functions emerging from the analysis themselves explained a noteworthy amount of the shared variance (25.6% and 17.8%). These two dimensions of the relationship were interpreted either as having to deaden one’s conscience relating to external demands in order to be able to collaborate with coworkers, or as having to deaden one’s conscience relating to internal demands in order to uphold one’s identity as a ‘good’ health care professional.

Juthberg C, Eriksson S, Norberg A, Sundin K. Perceptions of conscience in relation to stress of conscience. Nurs Ethics. 2007 May;14(3):329-343.

Conscientious Objection: A Potential Neonatal Nursing Response to Care Orders That Cause Suffering at the End of Life? Study of a Concept

Anita Catlin, Deborah Volat, Mary Ann Hadley, Ranginah Bassir, Christine Armigo, Elnora Valle, Wendy Gong, Kelly Anderson

Abstract
This article is an exploratory effort meant to solicit and provoke dialog. Conscientious objection is proposed as a potential response to the moral distress experienced by neonatal nurses. The most commonly reported cause of distress for all nurses is following orders to support patients at the end of their lives with advanced technology when palliative or comfort care would be more humane. Nurses report that they feel they are harming patients or causing suffering when they could be comforting instead. We examined the literature on moral distress, fi.itility, and the concept of conscientious objection from the perspective of the nurse’s potential response to performing advanced technologic interventions for the dying patient. We created a small pilot study to engage in clinical verification of the use of our concept of conscientious objection. Data from 66 neonatal intensive care and pediatric intensive care unit nurses who responded in a one-month period are reported here. Interest in conscientious objection to care that causes harm or suffering was very high. This article reports the analysis of conscientious objection use in neonatal care.

Catlin A, Volat D, Hadley MA, Bassir R, Armigo C, Valle E et al. Conscientious Objection: A Potential Neonatal Nursing Response to Care Orders That Cause Suffering at the End of Life? Study of a Concept. Neonatal Netw. 2008 Mar;27(2):101-108. Available from:

The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses

Venke Sørlie, Lilian Jansson, Astrid Norberg

Abstract
Twenty female Registered Nurses who had experienced being in ethically difficult care situations in paediatric care were interviewed as part of a comprehensive investigation into the narratives of male and female nurses and physicians about being in such situations. The transcribed interview texts were subjected to phenomenological-hermeneutic interpretation. The results showed that nurses appreciated social confirmation from their colleagues, patients and parents very much. This was a conditioned confirmation that was given when they performed the tasks expected from them. The nurses, however, felt that something was missing. They missed self-confirmation from their conscience. This gave them an identity problem. They were regarded as good care providers but at the same time, their conscience reminded them of not taking care of all the ‘uninteresting’ patients. This may be understood as ethics of memory where their conscience ‘set them a test’. The emotional pain nurses felt was about remembering the children they overlooked, about bad conscience and lack of self-confirmation. Nurses felt lonely because of the lack of open dialogue about ethically difficulties, for example, between colleagues and about their feeling that the wrong things were prioritized in the clinics. In this study, problems arose when nurses complied with the unspoken rules and routines without discussing the ethical challenges in their caring culture.

Sørlie V, Jansson L, Norberg A. The meaning of being in ethically difficult care situations in paediatric care as narrated by female Registered Nurses. Scand. J. Caring Sci. 2003;17(285-292.

Nurse supervisors’ actions in relation to their decision-making style and ethical approach to clinical supervision

Ingela Berggren, Elisabeth Severinsson

Extract
Findings. The essence of the nurse supervisors’ decision-making style is deliberations and priorities. The nurse supervisors’ willingness, preparedness, knowledge and awareness constitute and form their way of creating a relationship. The nurse supervisors’ ethical approach focused on patient situations and ethical principles. The core components of nursing supervision interventions, as demonstrated in supervision sessions, are: guilt, reconciliation, integrity, responsibility, conscience and challenge. The nurse supervisors’ interventions involved sharing knowledge and values with the supervisees and recognizing them as nurses and human beings.

Conclusion. Nurse supervisors frequently reflected upon the ethical principle of autonomy and the concept and substance of integrity. The nurse supervisors used an ethical approach that focused on caring situations in order to enhance the provision of patient care. They acted as role models, shared nursing knowledge and ethical codes, and focused on patient related situations. This type of decision-making can strengthen the supervisees’ professional identity. The clinical nurse supervisors in the study were experienced and used evaluation decisions as their form of clinical decision-making activity. The findings underline the need for further research and greater knowledge in order to improve the understanding of the ethical approach to supervision.

Berggren I, Severinsson E. Nurse supervisors’ actions in relation to their decision-making style and ethical approach to clinical supervision. J Adv Nurs. 2003;41(6):615-622.

Mandatory Overtime: Conflicts of Conscience

Jennell Charles

JONA's Healthcare Law, Ethics and Regulation — JONA’s Healthcare Law, Ethics and Regulation

Extract
This article attempts to engage only in a discussion of the ethical dimensions of mandatory overtime; the economic and empirical discussions are left for others to explore. Using the framework of “conscience,” we can begin to see some of the dynamics underlying the almost visceral reaction of some nurses to the issue of mandatory overtime.

Charles J. Mandatory Overtime: Conflicts of Conscience. JONA’s Healthcare Law, Ethics Reg. 2002;4(1):10-12.