Discussion
The aim of this study was to describe Swedish nurses' experiences of workplace stress and the occurrence of ethical dilemmas in a neurological setting. The results are in line with previous findings; ethical dilemmas cause distress among nurses (Kälvemark et al., 2004). Key components found in all content areas were high workload and nurses' difficulties with regard to influencing their working environment and decisions regarding patients' care. The relationships and cooperation with other healthcare team members were described as not quite satisfactory, and the nurses had an ambivalent view of the role of the family. There was a general satisfaction with the quality of nursing care, but a lack of time and nursing staff always threatened this quality. The nurses described different ways of managing the distress and the dilemmas; they mainly accepted and adjusted to the situation and sought support from colleagues.
The main causes of workplace distress were the demanding working situation and workload and a lack of influence. Distress caused by a heavy workload—due to a shortage of staff in relation to the number of patients—is in line with findings in previous studies (Hertting et al. 2004; Olofsson et al., 2003). This had consequences for the quality of nursing care, which was thought to be unsatisfactory when nurses did not have time to meet patients' needs. A lack of time may imply that the nurses have to set priorities that are contradictory to their nursing principles (Cronqvist et al., 2001). Nurses are also in a position where they often lack influence over their working situation and the decisions they have to follow through on (Oberle & Hughes, 2001), which was evident in the present study. One kind of stress nurses may experience is moral distress. Jameton (1984) defined moral distress as occurring when "one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (p. 6).
This definition was further developed by Wilkinson (1987), who defined such distress as "the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behaviors indicated by that decision" (p. 16). The nurses in this study expressed moral distress in terms of wanting to do the best for their patients but being hindered by a shortage of staff, routines, and economic factors. The nurses' descriptions of fatigue, frustration, and inadequacy are also in line with Wilkinson's report documenting the negative feelings that moral distress produces. The consequences of moral distress are serious, the most extreme such consequence being that nurses leave the nursing profession altogether (Wilkinson). Chambliss (1996) argued that ethical problems and the resulting distress should not be viewed as isolated incidents or as personal issues, but as systematic issues created by the hospital organization. This perspective is applicable to the present study, because the results indicate a high level of concordance among the nurses regarding what was viewed as stressful, and these issues were mainly related to organizational factors.
The most common ethical dilemmas revolved around making decisions about whether to initiate or withdraw treatment. In accordance with previous research (Oberle & Hughes, 2001), the nurses in this study found the decision-making situation difficult, and the main dilemma to be deciding when suffering outweighed the benefits of treatment. The nurses perceived that in some cases the decision was made too late. This indicates that in their opinion a greater number of patients should receive limited treatment, which is in line with previous studies (Bucknall & Thomas, 1997; Hildén, Louhiala, Honkasalo, & Palo, 2004), but they also expressed the opinion that decisions to limit or withdraw treatment could be made too early. At the same time, the nurses perceived that they were left out of the decision-making process. This may imply that they did not have sufficient information about a physician's decision, and this resulted in their holding a different opinion regarding the level of treatment. Several studies (Bucknall & Thomas; Ferrand et al., 2003, Manias, 1998; Rocker et al., 2005) have described nurses' conceptions of being left out of decision making regarding treatment; in the present study the nurses expressed the opinion that this had negative consequences for the care of the patient. The inclusion of nurses in the decision-making process could have several advantages. First, the nurses complement the medical basis for decision making with their knowledge about the patient. If nurses are given the opportunity to discuss decisions with the physician, nurses may find it easier to care for patients even if the they do not agree with the physician's decision. Disagreements regarding aggressiveness of treatment also arose between staff members and family. In this instance, nurses were ambivalent about families' participation. The view of the family as having too much influence is in line with previous results (Hildén et al.; Viney, 1996). However, the ambivalence about the role of the family was not found in previous research.
When it came to managing distress and ethical dilemmas, the nurses primarily relied on coping strategies, and planned discussions about it were rare. Seeking support from colleagues was a common strategy, which is in accordance with the results in another Swedish study (Cronqvist et al., 2006). Nurses may turn to each other for support because they feel more comfortable with colleagues they know than people unknown to them—as may be the case if these situations are discussed in a larger group. But it may also reflect nurses' perception that there is a lack of organized support at the workplace (Cronqvist et al., 2006), which some of the nurses expressed in the present study. Kälvemark and colleagues (2004) found that discussions about ethical issues occurred most often during coffee breaks, and it was only when there had been an especially difficult situation that the nurses met for a more formal discussion.
Systematic clinical nursing supervision has been suggested as one way to handle distress. It has been shown to increase nurses' moral sensitivity, but on the other hand, nurses who were under clinical supervision reported higher levels of stress than nurses who were not (Severinsson & Kamaker, 1999). Organized discussions on ethical problems may be in the form of ethics rounds, where hearing others share their perspectives and experiences can help clarify one's own standpoint. The participants listen to one another's opinions, and in that way values at stake for all concerned are identified (Hansson, 2002). There are few studies that discuss the value of ethics rounds, but in one study (Raines, 2000), the nurses ranked them among the least helpful support resources when dealing with ethical issues. However, this is an area that needs further investigation. If, as Chambliss (1996) argued, nurses' distress reflects organizational problems, managing the distress cannot solely be a question of enhancing the communication among members of the healthcare team, increasing the amount of education, or holding ethics seminars—changes at the organizational level are also required.
Because little is known about neuroscience nurses' experiences of workplace distress and ethical dilemmas, a qualitative method was used. This is the method recommended when there is little or no literature describing the population in question (Brink & Wood, 1998). When a qualitative method is used, it is often impossible to generalize the findings to a broader group. Another limitation of this study was that the sample was taken from one hospital. However, the trustworthiness of this study is strengthened by previous research; the main results of this study are in accordance with those in previous studies. Lambert and colleagues (2004) found that nurses working in different countries reported similar workplace stressors, and therefore the findings may be transferable to other neurological departments and healthcare settings similar to the Swedish system.
J Neurosci Nurs. 2008;40(4):222-231. © 2008 American Association of Neuroscience Nurses
Cite this: Workplace Distress and Ethical Dilemmas in Neuroscience Nursing - Medscape - Aug 01, 2008.
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