In the previous four papers in this series, individual versus structural or contextual factors have informed various understandings of moral distress. In this final paper, we summarize some of the key tensions raised in previous papers and use these tensions as springboards to identify directions for action among practitioners, educators, researchers, policymakers and others. In particular, we recognize the need to more explicitly politicize the concept of moral distress in order to understand how such distress arises from competing values within (...) power dynamics across multiple interrelated contexts from interpersonal to international. We propose that the same socio-political values that tend to individualize and blame people for poor health without regard for social conditions in which health inequities proliferate, hold responsible, individualize and even blame health care providers for the problem of moral distress. Grounded in a critical theoretical perspective of context, definitions of moral distress are re-examined and refined. Finally, recommendations for action that emerge from a re-conceptualized understanding of moral distress are provided. (shrink)

How ethical praxis is shaped by different contexts and situations has not been widely studied. We performed a follow-up study on stroke team members’ experiences of ethical problems and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. A number of ways for handling ethical problems emerged, which we have now explored further. Data were collected through a three-part form used as base for individual interviews with 15 stroke team members and (...) analyzed using both quantitative and qualitative content analysis. In the analysis, the approaches in the form were condensed into strategies, and the two different ways those strategies were preferred and used by the team members were shown. Hindrances perceived by the team members to impede them from working the preferred way were also revealed and grouped into eight categories. (shrink)

Background: In end of life care, ethical problems often come to the fore. Little research is performed on ways or strategies for handling those problems and even less on obstacles to and possibilities of using such strategies. A previous study illuminated stroke team members’ experiences of ethical problems and how the teams managed the situation when caring for patients faced with sudden and unexpected death from stroke. These findings have been further explored in this study. Objective: The aim of the (...) study was to illuminate obstacles and possibilities perceived by stroke team members in using strategies for handling ethical problems when caring for patients afflicted by sudden and unexpected death caused by stroke. Research design: A qualitative method with combined deductive and inductive content analysis was utilized. Participants and research context: Data were collected through individual interviews with 15 stroke team members working in stroke units of two associated county hospitals in western Sweden. Ethical considerations: The study was approved by the Regional Ethics Review Board, Gothenburg, Sweden. Permission was also obtained from the director of each stroke unit. Findings: All the studied strategies for handling of ethical problems were found to have both obstacles and possibilities. Uncertainty is shown as a major obstacle and unanimity as a possibility in the use of the strategies. The findings also illuminate the value of the concept “the patient’s best interests” as a starting point for the carers’ ethical reasoning. Conclusion: The concept “the patient’s best interests” used as a starting point for ethical reasoning among the carers is not explicitly defined yet, which might make this value difficult to use both as a universal concept and as an argument for decisions. Carers therefore need to strengthen their argumentation and reflect on and use ethically grounded arguments and defined ethical values like dignity in their clinical work and decisions. (shrink)

When people die suddenly and unexpectedly ethical issues often come to the fore. The aim of the study was to describe experiences of members of stroke teams in stroke units of ethical problems and how the teams manage the situation when caring for patients faced with sudden and unexpected death from stroke. Data were collected through four focus group interviews with 19 team members in stroke-unit teams, and analysed using interpretive content analysis. Three themes emerged from the analysis characterized by (...) information, decisions about care and support for the next-of-kin in the changing and uncertain situation, with mutual trust as the core. Mutual trust, both within the stroke team and with next-of-kin was seen by the stroke-team members as a way of handling ethical problems by administering care with the patient’s best interest at heart. (shrink)

Background:Attention to ethical leadership in nursing has diminished over the past several decades.Objectives:The aim of our study was to investigate how frontline nurses and formal nurse leaders envision ethical nursing leadership.Research design:Meta-ethnography was used to guide our analysis and synthesis of four studies that explored the notion of ethical nursing leadership.Participants and research context:These four original studies were conducted from 1999-2008 in Canada with 601 participants.Ethical considerations:Ethical approval from the original studies covered future analysis.Findings:Using the analytic strategy of lines-of-argument, we (...) found that 1) ethical nursing leadership must be responsive to practitioners and to the contextual system in which they and formal nurse leaders work, and 2) ethical nursing leadership requires receiving and providing support to increase the capacity to practice and discuss ethics in the day-to-day.Discussion and conclusion:Formal nurse leaders play a critical, yet often neglected role, in providing ethical leadership and supporting ethical nursing practice at the point of patient care. (shrink)

There is increasing emphasis on the need for collaboration between practice and academic leaders in health care research. However, many problems can arise owing to differences between academic and clinical goals and timelines. In order for research to move forward it is important to name and address these issues early in a project. In this article we use an example of a participatory action research study of ethical practice in nursing to highlight some of the issues that are not frequently (...) discussed and we identify the impact of things not-named. Further, we offer our insights to others who wish to be partners in research between academic and practice settings. These findings have wide implications for ameliorating misunderstandings that may develop between nurse leaders in light of collaborative research, as well as for participatory action research. (shrink)

Background:Nurse managers are expected to continuously ensure that ethical standards are met and to support healthcare workers’ ethical competence. Several studies have concluded that nurses across various healthcare settings lack the support needed to provide safe, compassionate and competent ethical care.Objective:The aim of this study was to explore and understand how nurse managers perceive their role in supporting their staff in conducting ethically sound care in nursing homes and home nursing care.Design and participants:Qualitative individual interviews were performed with 10 nurse (...) managers with human resources responsibilities for healthcare workers in four nursing home wards and six home nursing care districts. Content analysis was used to analyse the data.Ethical considerations:The Norwegian Centre for Research Data granted permission for this study.Findings:The analysis resulted in seven subcategories that were grouped into three main categories: managers’ perception of the importance of the role, managers’ experiences of exercising the role and managers’ opportunities to fulfil the role. Challenges with conceptualizing ethics were highlighted, as well as lack of applicable tools or time and varying motivation among employees.Discussion:The leaders tended to perceive ethics as a ‘personal matter’ and that the need for and benefit of ethical support (e.g., ethics reflection) depended on individuals’ vulnerability, attitudes, commitment and previous experiences. The managers did not seem to distinguish between their own responsibility to support ethical competence and the responsibility of the individual employee to provide ethical care.Conclusions:Our findings suggest that nurse managers need support themselves, both to understand and to carry out their responsibilities to foster their staffs’ ethical conduct. Supporting staff in conducting ethically sound care requires more than organizing meeting places for ethical reflection; it also requires greater awareness and understanding of what ethical leadership means. (shrink)