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Aim To examine the relative effects of interpersonal conflict and workload on job outcomes (turnover intentions, burnout, injuries) and examine if resilience moderates the indirect effects of conflict and workload on job outcomes via job-related negative affect. Background There is interest in understanding resilience in the nursing profession. Placing resilience in the context of the Emotion-Centered Model of Occupational Stress (Spector, 1998) is a novel approach to understanding how resilience ameliorates the negative effects of workplace stressors. Design This study used a two-wave survey design to collect data from 97 nurses across medical units. Methods Nurses working in the United States were recruited in June 2014 using Qualtrics Panels, an online survey platform service that secures participants for research. Nurses were contacted via email at two time points, two weeks apart and provided a link to an online survey. SPSS v. 23 and PROCESS v2.15 were used to analyze regressions and moderated mediation. Results/Findings Interpersonal conflict predicted turnover intentions and burnout; workload predicted injuries. Job-related negative affect mediated the relationships between stressors and job outcomes except for the direct effect of workload on injuries. Low resilience increased the magnitude of the indirect effects of conflict on job outcomes. Conclusion Job characteristics like workload predicted unique variability in self-reported physical injuries. Conflict at work, a social stressor, predicted well-being and job attitudes. Highly resilient nurses bounced back after experiencing conflict in the workplace. Resilience should be explored for its potential as a method to reduce the negative effects of social stressors. This article is protected by copyright. All rights reserved.

Aim To explore and understand moral distress from the perspective of and as experienced by critical care nurses in Korea. Background The concept of moral distress among critical care nurses must be more broadly explored using a qualitative approach. Design Giorgi's phenomenological research approach was used. Methods A purposive sampling was used to select 14 critical care nurses. In-depth face-to-face interviews were performed in Korea from March 2012–December 2013. Findings Five main themes of moral distress emerged: (1) ambivalence towards treatment and care (notably prioritizing work tasks over human dignity, unnecessary medical treatments and the compulsory application of restraints); (2) suffering resulting from a lack of ethical sensitivity; (3) dilemmas resulting from nurses' limited autonomy in treatments; (4) conflicts with physicians; and (5) conflicts with institutional policy. Conclusion Staff shortages are aggravated by high staff turnover caused by ethical suffering. The resulting lack of staff can, in turn, give rise to added ethical conflicts as part of a vicious circle, leading to decreased patient satisfaction.

Aim: The aim of this study was to find out if student nurses feel comfortable in caring by providing support for Lesbian, Gay, Bisexual or Questioning adolescents and what factors influence their level of comfort.\ud \ud Background: Research indicates that nurses and nursing students experience varying levels of comfort when caring for adults who are Lesbian, Gay, Bisexual or Questioning: adult patients feel that nurse’s attitudes change towards them once they disclose their sexuality. There has been minimal research to date on nursing attitudes to working with adolescents who are Lesbian, Gay, Bisexual or Questioning.\ud \ud Design Both quantitative and qualitative methods were used in this descriptive study. Questionnaires were completed by 152 nursing students and 9 took part in semi-structured focus groups.\ud \ud Method: A two way ANOVA was used to analyse the questionnaires. Thematic analysis was used to identify the themes arising from the focus groups. Data was collected between August 2013 and July 2014. \ud \ud Results/Findings: The results and findings of the study were that student nurse’s felt discomfort in providing support; due to a lack of knowledge of Lesbian, Gay or Bisexual sexuality, personal and religious beliefs and the perceptions of others. However, all students indicated they had a positive attitude towards Lesbian, Gay, Bisexual and Questioning adolescents.\ud \ud Conclusion: More needs to be done to raise self-awareness and improve the level of knowledge in relation to Lesbian, Gay and Bisexual issues amongst student nurses. Educational institutions and practice areas need to recognize this fact and reflect this in their educational programmes.

Aim To report the moderating effects of work-related conditions and interactive family-care-giving variables, including mutuality and preparedness, on caregiver role strain and mental health for family caregivers of patients with dementia. Background Few studies have examined the interrelationships among caregivers' working conditions, care-giving dynamics and caregiver well-being. Design Cross-sectional, correlational study. Methods Data were collected by self-completed questionnaires from 176 primary family caregivers of patients with dementia in Taiwan from May 2005-January 2006. Caregiver role strain and mental health were analysed by multiple regressions using a hierarchical method to enter independent variables and two- and three-way interaction terms after controlling for caregiver age and gender, employment status, and work flexibility and the simple effect of each independent variable. Results More preparedness was associated with less role strain for family caregivers with less work/care-giving conflict. More care-giving demand was associated with poorer mental health only for caregivers with low work/care-giving conflict and with average and low preparedness, but not high preparedness. For family caregivers with less work/care-giving conflict, more preparedness decreased role strain and maintained mental health even when care-giving demand was high. Conclusion These results provide a knowledge base for understanding complex family caregiver phenomena and serve as a guide for developing interventions. Future studies with longitudinal follow-ups are suggested to explore actual causal relationships.

hoye s. & severinsson e. (2010) Professional and cultural conflicts for intensive care nurses. Journal of Advanced Nursing66(4), 858–867. Abstract Title. Professional and cultural conflicts for intensive care nurses. Aim. This paper is a report of a study exploring intensive care nurses’ experiences of conflicts related to practical situations when they encounter culturally diverse families of critically ill patients. Background. Conflicts can arise in critical care settings as a result of differing cultural and professional values. Nurses and families with diverse cultural backgrounds bring beliefs and understandings to the care situation that can have an impact on the care process. Such families are challenged in their efforts to maintain traditions, while some nurses are not sufficiently culturally aware. A limited number of studies have focused on such conflicts. Method. Sixteen critical care nurses took part in multistage focus group interviews conducted from October 2005 to June 2006. The data were analysed using qualitative content analysis. Findings. The main theme, ‘conflict between professional nursing practice and family cultural traditions’, was based on three pairs of conflicting themes: ‘culturally based need to participate actively in the care vs. nurses’ professional perceptions of themselves as total care providers’; ‘nurses’ professional obligation to provide comprehensible information vs. culturally based communication difficulties and responses to illness’; and ‘families’ needs for cultural norms and self-determination vs. nurses’ professional responsibility for the clinical environment’. In addition, each pair of themes contained several sub-themes. Conclusion. Nurses need to negotiate with culturally diverse family members to address conflicts. In their encounters with such families, they should establish a balance between ethnocentricity and cultural sensitivity. An implication for practice is to increase nurses’ competence in assessment of diversity.

Title. Nurses' satisfaction with shiftwork and associations with work, home and health characteristics: a survey in the Netherlands. Aim. This paper is a report of a study conducted to determine if satisfaction with irregular working hours that are a form of shiftwork operates as a mediator between work and home characteristics and health problems. Background. Shiftwork contributes to health problems, decreased well-being and poorer health habits. It also affects employees’ decisions to leave the healthcare sector. Although many nurses voluntarily work shifts, there have been few studies of their satisfaction with irregular working hours when these are a form of shiftwork. Methods. A survey was carried out with 144 nurses working in three nursing homes and one care home in the Netherlands. Questionnaires were distributed in 2003 to 233 nurses who worked shifts (response rate 60%). The questionnaire contained items on work and home characteristics, satisfaction with irregular working hours that are a form of shiftwork and health. A new scale to measure satisfaction with irregular working hours was constructed. Results. All work characteristics, but no home characteristics, were associated with satisfaction with irregular working hours. The work characteristics ‘job demands’ and the home characteristics ‘autonomy at home’ and ‘home demands’ were associated with health. Satisfaction with irregular working hours did not mediate between work/home characteristics and health. Those reporting more social support, lower job demands and more job autonomy were more satisfied with their irregular working times that were a form of shiftwork. Conclusions. Satisfaction with irregular working hours is a useful construct that requires further longitudinal study. The results also underline the importance of considering home characteristics when predicting health outcomes.

Title. Work-home interference among nurses: reciprocal relationships with job demands and health. Aims. This paper is a report of a study with three aims: (i) to investigate whether emotional, quantitative and physical demands have a causal, negative impact on nurses' health; (ii) to examine whether work-home interference can explain this effect, by playing a mediating role; and (iii) to test the so-called loss spiral hypothesis claiming that nurses' health problems lead to even higher job demands and more work-home interference over time. Background. While many scholars have thought in terms of the stressor¿work-home interference¿strain model, the validity of a model that includes opposite pathways needs to be tested. Method. A questionnaire was completed twice, with a 1-year time interval by 753 (63·4%) Registered Nurses working in hospitals, 183 (15·4%) working in nursing homes, and 251 (21·1%) working in home care institutions. The first measurement took place between October 2002 and June 2003. Findings. Our findings strongly support the idea of cross-lagged, reciprocal relationships between job demands and general health over time. The reciprocal model with work-home interference as an intervening variable (including reciprocal relationships between job demands, work-home interference and general health) showed a good fit to the data, and proved to be superior to both the causality and reversed causation models. Conclusion. The higher nurses' job demands, the higher is their level of work-home interference and the more likely is a general health deterioration over time, in turn giving rise to higher job demands and work-home interference, which may even aggravate the nurses' general health, and so on.

Aim To review empirical studies examining antecedents (sources, causes, predictors) in the management and mitigation of interpersonal conflict. Background Providing quality care requires positive, collaborative working relationships among healthcare team members. In today's increasingly stress-laden work environments, such relationships can be threatened by interpersonal conflict. Identifying the underlying causes of conflict and choice of conflict management style will help practitioners, leaders and managers build an organizational culture that fosters collegiality and create the best possible environment to engage in effective conflict management. Design Integrative literature review. Data sources CINAHL, MEDLINE, PsycINFO, Proquest ABI/Inform, Cochrane Library and Joanne Briggs Institute Library were searched for empirical studies published between 2002–May 2014. Review methods The review was informed by the approach of Whittemore and Knafl. Findings were extracted, critically examined and grouped into themes. Results Forty-four papers met the inclusion criteria. Several antecedents influence conflict and choice of conflict management style including individual characteristics, contextual factors and interpersonal conditions. Sources most frequently identified include lack of emotional intelligence, certain personality traits, poor work environment, role ambiguity, lack of support and poor communication. Very few published interventions were found. Conclusion By synthesizing the knowledge and identifying antecedents, this review offers evidence to support recommendations on managing and mitigating conflict. As inevitable as conflict is, it is the responsibility of everyone to increase their own awareness, accountability and active participation in understanding conflict and minimizing it. Future research should investigate the testing of interventions to minimize these antecedents and, subsequently, reduce conflict.

Aims To investigate the mediating effect of work-to-family conflict on the relationship between job satisfaction and turnover intention among licensed nurses in long-term care settings. Background The considerable research on turnover in long-term care has primarily focused on the impact of job satisfaction on turnover intention. Given the well-documented high turnover rate in nursing home staffing, dissatisfaction is expected to continue. Alternatives (e.g. reduction in work-to-family conflict) for reducing turnover under the circumstance of job dissatisfaction have not been investigated extensively. Design A cross-sectional mailed survey. Methods A convenience sample comprising 200 nurses from 25 private nursing homes in Central Taiwan was created. Data were collected from nurses about their level of turnover intention, job satisfaction and work-to-family conflict in 2012. A composite indicator structural equation model was used to examine the mediation model of this study. Results Overall, 186 nurses (93%) returned the completed questionnaires. Consistent with published research from other countries, turnover intention in our study was significantly and negatively associated with job satisfaction and significantly and positively associated with work-to-family conflict. In addition, job dissatisfaction indirectly influenced turnover intention through high work-to-family conflict. Conclusion Findings from this study indicate the importance of work-to-family conflict to nurse turnover. While work setting has a strong, well-documented influence on job satisfaction, limiting job satisfaction efforts to work setting improvements may not yield the hoped-for results unless work-to-family conflict is also considered and addressed.

Aims The aim of this study was to examine nurses' perceptions of constructive and destructive conflicts and their management among nurses. Background Conflict among nurses is common and has been associated with lack of collaboration, lack of communication and disruptive behaviour, with the potential to have negative impact teamwork. However, unlike the broader social science literature, positive views of conflict are scarce in the nursing literature. Given the various functions of conflict and the high stakes of ineffective conflict management in nursing, it is necessary to examine how nurses understand both sides of conflict: constructive and destructive. Design A qualitative descriptive design. Methods Data were collected from 34 full time nurses as part of a conflict skills training course offered over 6 months beginning in October 2009. Each participant was asked to write a weekly journal about conflicts in his/her work place. Result Data yielded 163 entries (82 classified as constructive and 81 as destructive). Results showed that quality patient care and cooperative communication contributed to the perception that conflict is constructive in nature. The central underlying themes in nurses' perceptions of destructive conflict were time constraints, role conflict and power differences that are not managed through communication. Conclusion This article helps to identify nursing perceptions of constructive and destructive conflict and to understand complexities nurses face during their interactions with other nurses, physicians and patients. The insight that constructive views are related to constructive processes provides an excellent opportunity for an educational intervention, so that we can educate nurses to analyse problems and learn how to manage conflict with effective collaborative processes.

Aim. The aim of this paper is to report a study of the lived experience of postpartum stress among depressed Hong Kong Chinese mothers. Background. Research consistently relates postpartum stress to the mood and well-being of mothers during the postpartum period. While several studies have used questionnaires to assess the stress levels of mothers or have identified stressors by asking them to list stressful events, the existing literature lacks in-depth information on the lived experience of postpartum stress from the perspective of the depressed mother. Methods. The study adopted a phenomenological approach with a purposive sample of 11 depressed Hong Kong Chinese mothers at around the sixth postpartum month. In-depth interviews were conducted in Cantonese and focused on the stress the mothers experienced during the postpartum period up to the time of the interview. The data were collected in 2000. Results. Living in a metropolitan city under the mixed and sometimes conflicting influences of cultures from the East and the West, Hong Kong Chinese mothers face a unique set of challenges which, if not properly managed, may cause stress and/or depression in the postpartum period. We identified five major postpartum stress themes amongst this group of women: parenting competence, the expectation–experience gap, baby-minder arrangements, childcare demands, and conflict with culture and tradition. Conclusions. Health care staff should give anticipatory guidance to mothers and their spouses about the culturally prescribed set of rules that proved stressful. Antenatal education classes need to enhanced, and support is needed to help this population of women manage and overcome the challenges in the postpartum period.

Aims To study relationship management strategies of daughters in conflicted relationships with their mothers and how they promoted or prevented elder abuse. Background Daughters have enduring, unique relationships with their mothers that often carry over into caregiving. Pre-caregiving relationship quality is related to many caregiving outcomes, although it is unclear how. Design Qualitative study. Methods Grounded theory design, informed by feminism, with telephone interviews conducted between January 2013–July 2013. The sample (N = 13) was recruited through an online recruitment strategy, with advertisements posted on relevant websites asking ‘Are you in an abusive relationship with your ageing mother?’ Results/findings Daughters used coping strategies and self-protective strategies aimed at decreasing their exposure to aggression and emotional distress when interacting with their ageing mothers. Daughters also used spiteful aggression out of the desire for revenge. Conclusion Although the daughters' strategies served their personal needs, they jeopardized the mothers' needs by creating an environment where neglect could occur. Daughters also readily and intentionally used aggression against their mothers. These were strategies daughters have found useful. These strategies may be potential areas for designing interventions to promote healthy family relationships and decrease the occurrence of elder abuse and neglect.

Aim To describe the life experiences of adolescents and young adults with congenital heart disease. Background Owing to medical advances, most children with congenital heart disease are expected to survive into adulthood. The transitional development from adolescence to adult is the critical period for fostering self-care. Design Descriptive phenomenological study. Methods Thirty-five patients of 15–24 years old with congenital heart disease were recruited from paediatric cardiology clinics by purposive sampling. They were individually interviewed between October 2012–February 2013 using a semi-structured interview guideline and joined adult congenital heart disease clinics at two medical centres in northern Taiwan. The data were analysed using descriptive phenomenological method developed by Giorgi. Findings The essence of the life experience of adolescents and young adults with congenital heart disease involves a dynamic process of moving between invisible defects and coexistence with the disease. Six themes emerged: (1) invisible defects: the existence of imperfect understanding; (2) conflict: interpersonal frustrations; (3) imbalance: the loss of self-balance; (4) suffering: increasing anxiety; (5) encounters: meeting needs; and (6) coexistence: positive coping strategies. Conclusion As patients with congenital heart disease transition from adolescence into adulthood, they must learn about their disease, overcome frustration and anxiety and develop self-care strategies for coexisting with congenital heart disease. Results of this study may serve as clinical care guidelines for adolescents and young adults with congenital heart disease and give a reference for developing transitional intervention strategies.

Seniors’ decision making about pain management Background. Muscoloskeletal pain is a problem with which many seniors must contend, many on a daily basis. Little is known, however, of the self-care decisions that seniors make regarding the management and control of this pain. These decisions can influence in a significant manner the delivery of health care to seniors and their overall health and well-being. Purpose. The purpose of our exploratory-descriptive study was to investigate seniors’ decision making regarding the management and control of musculoskeletal pain by gathering data about the context of decision making, the types of decisions seniors made, their decisional conflict and the resources they used in decision making. Methods. Focus groups and a mail-back questionnaire were used. Data were gathered in 1997 from a convenience sample of 50 seniors in Canada who experienced musculoskeletal pain of a noteworthy nature. Results. Findings revealed that participants made decisions within a context of ageing and the health and social consequences of advancing age. The types of decisions they made included to ignore their pain and to use distraction. They also used exercise, the application of heat and cold, and medications to manage pain. Decisional conflict was minimal and consultation with family and friends superseded that with professionals. Conclusions. This study contributed to knowledge of decision making in later life about health matters generally, and the management and control of pain specifically. Findings point to the resourcefulness of seniors with respect to self-care and decision making. Seniors want to make informed decisions. However, they need information about the risks and benefits of decisions.

Subject positions theory – its application to understanding collaboration (and confrontation) in critical care Background. Doctors and nurses do not usually take a collaborative approach to the ethical challenges of the critical care environment. This leads to the stresses that produce moral anguish and burnout – both for nursing and medical staff. A more collegial relationship between nurses and physicians should improve patient care. If we are to promote this collegiality, one way to proceed is to investigate the interactions between health care professionals in order to develop an understanding of the barriers to, and supports for collaboration. Aim. Subject positions theory offers a method of explaining and elucidating the interactions between nurse and physician in terms of power dynamics, mutual expectations and the discourse available to each individual. This paper aims to demonstrate how subject positions theory can facilitate the interpretation of the interactions between health professionals in terms of the power dynamics influencing those interactions. Discussion. This paper will use the example of a case study from my own research to demonstrate the application of this theory and its usefulness in the analysis of the interactions between health care professionals. Conclusions. Application of this theory is used to demonstrate the author’s argument that the current political and cultural structure of the health care system does not support the subject position – nurse advocate.

Technology and humane nursing care: (ir)reconcilable or invented difference? Aim(s) of the paper. This paper questions the validity of a boundary presumed to exist between technology and humane care. It argues the need for reconciliation of presumed tension(s) between technology and person focused care and the need to reconsider our ways of understanding the relations between technology and nursing. Background/rationale. Recent scholarship in the social sciences related to reproductive and imaging technologies and emergency resuscitation are examined and arguments are presented that question the appropriateness of a humanist view that emphasizes technology on the nonhuman and nonnatural side of a human/nonhuman, nature/artifice divide. It is argued that what determines experiences such as dehumanization is not technology per se but how individual technologies are used and operate in specific user contexts, the meanings that are attributed to them, how individuals or cultural groups define what is human, and the organizational, human, political and economic technological system (technique) that creates rationale and efficient order within nursing, health care and society. Conclusion. The paper concludes by asking whether the commonplace appeal to resolve tensions between humane care and technology has erroneously highlighted technology as the reason for impersonal care, and encourages re-examination of the relationship(s) between technology, humane care and nursing practice.

Doctors’ and nurses’ perceptions of ethical problems in end-of-life decisions Aims. To identify and compare doctors’ and nurses’ perceptions of ethical problems. Rationale. Ethical problems are a source of tension for health professionals. Misunderstandings or conflicts may result from differing perceptions of ethical problems. If true collaboration is to be achieved, it is important to understand the perspectives of others, particularly when difficult end-of-life decisions must be made. Methods. In this qualitative study a total of seven doctors and 14 nurses working in acute care adult medical-surgical areas, including intensive care, were asked to describe ethical problems that they frequently encounter in practice. Interviews were taped and transcribed. Thematic analysis followed. Results. All participants experienced ethical problems around decision making at the end of life. The core problem for both doctors and nurses was witnessing suffering, which engendered a moral obligation to reduce that suffering. Uncertainty about the best course of action for the patient and family was a source of moral distress. Competing values, hierarchical processes, scarce resources, and communication emerged as common themes. The key difference between the groups was that doctors are responsible for making decisions and nurses must live with these decisions. Each group, therefore, asked different questions when encountering and interpreting sources of moral distress. Conclusions. It was concluded that observed differences between doctors and nurses were a function of the professional role played by each rather than differences in ethical reasoning or moral motivation. Although this was a small qualitative study on one institution, and may not be generalizable, results suggest that doctors and nurses need to engage in moral discourse to understand and support the ethical burden carried by the other. Administrators should provide opportunities for discourse to help staff reduce moral distress and generate creative strategies for dealing with this.

Aims. Stressors, coping and demographic variables were examined as predictors of burnout in a sample of hospice nurses. The study aimed to investigate the level of burnout among hospice nurses; to ascertain which aspects of nursing work were positively or negatively related to burnout; to examine the relative contributions made by these different variables and to suggest individual and organizational interventions to reduce levels of burnout. Methods. Eighty-nine female nurses from nine hospices completed a battery of questionnaires comprising the Maslach Burnout Inventory, Nursing Stress Scale, Ways of Coping Scale and a demographic information form. Results. In general, the level of burnout (characterized by high emotional exhaustion, high depersonalization of patients and low personal accomplishment) was found to be low. In multiple regression analyses, 'death and dying', "conflict with staff', 'accepting responsibility' and higher nursing grade contributed to emotional exhaustion. 'Conflict with staff', 'inadequate preparation', 'escape' and reduced 'planful problem-solving' contributed to depersonalization. 'Inadequate preparation', 'escape', reduced 'positive reappraisal' and fewer professional qualifications contributed to lower levels of personal accomplishment. Overall, stressors made the greatest contribution to burnout and demographic factors contributed the least. Conclusions. The importance of not labelling individuals as good and bad 'copers' was discussed, as the effectiveness of a strategy may depend on the situation. It was concluded that the investigation of problem-focused and emotion-focused coping in relation to burnout, was oversimplifying the coping-burnout relationship. Suggestions for stress management included staff training in counselling skills, monitoring staff conflict, implementing stress inoculation training to teach appropriate use of coping skills and finally, monitoring particularly vulnerable groups of hospice staff such as unqualified nursing assistants and qualified nurses in management positions. It was concluded that despite the difficult nature of hospice work, the hospice is a positive environment in which to work.

Tacit definitions of informal caregiving Aims of the study: This study describes three tacit definitions of informal caregiving and explores the extent to which differences in these tacit definitions explain variation in caregivers’ negative mood over time. Background/Rationale: There is a growing need to understand the sources of stress and gratification for informal caregivers. Tacit definitions of informal caregiving refer to caregivers’ understanding of what caregiving entails. These definitions are tacit because they arise from caregivers’ taken-for-granted understanding rather than formally articulated positions concerning caregiving. Design/Methods: A random sample of 60 men, all of whom were caregiving partners of men with acquired immunodeficiency syndrome (AIDS), was drawn from a larger cohort of 253 participants in the University of California San Francisco (UCSF) Coping Project (1990–1997). The caregivers were assessed bimonthly for 2 years with procedures that included a semi-structured interview focusing on a recent stressful event involving caregiving, and quantitative measures of well-being. Results/Findings: Interpretive phenomenological case studies of the narrative accounts of the 60 caregivers produced three tacit definitions of caregiving – engagement, conflict and distance. These three tacit definitions were distinguished by differences in learning about caregiving, involvement in health care decisions, caregiving activities and reported sources of stress. The three groups differed on measures of dyadic adjustment, depression, anger and anxiety. Conclusions: Better understanding of caregivers’ tacit definitions can facilitate and enhance effective support and interventions for caregivers.

Whistleblowing - the public exposure of organizational wrongdoing - presents practical and ethical dilemma for nurses, and needs to be seen as part of a spectrum of increasingly confrontative actions against miscreant organizations by their employees. The ethics of whistleblowing can only be understood in relation to its moral purpose, whether that is to achieve a good outcome (a consequentialist view) or fulfil a duty (a deontological view). The consequentialist perspective is unable on its own to resolve problems arising from the balance of good and harm resulting from the act of whistleblowing (where considerable harm might be caused) or of responsibility for that harm. A deontological approach provides an analysis of these problems but raises its own problem of conflicting duties for nurses. However, a strong argument can be made for the precedence of the nurse's duty to the patient over her duty to the employer. Although both duties are based on an implicit or an explicit promise, the promise to a person (the patient) must take precedence over the promise to an organization. It can even be argued that duty to the employer may in fact justify whistleblowing by nurses in some circumstances. However, the consequences of whistleblowing are forced upon nurses in a different way by the fact that the danger of reprisals acts as a deterrent to whistleblowers, however justified their actions may be. A more robust approach to the protection of whistleblowers is needed on the part of the government and the National Health Service (NHS) to remedy this situation.

Nurses' experiences of being present with a patient receiving a diagnosis of cancer This paper reports the findings of a study which describes the experiences of nurses who were present with a patient when they received a diagnosis of cancer, cancer recurrence or prognosis of terminal cancer. Semi-structured interviews were conducted with six nurses who had experience of caring for patients with cancer in an acute surgical setting. Data were analysed using a phenomenological descriptive approach. Participants' descriptions revealed the following seven core themes: 'What if it was me?'; divergent feelings; being there; becoming closer; method of disclosure; time as an influence and learning by reflection. Possible implications for nursing practice and education are discussed and recommendations are made for future research.

Nurses, like other groups throughout history, have been described as an oppressed group. Writers who describe nurses as lacking in self-esteem, autonomy, accountability and power support this view in the literature. Indeed the cultural narration of nursing is for nurses to be subordinate. This article explores the emergence of horizontal violence within nursing and suggests that it is a result of unexpressed conflict within an oppressed group. The author aims to raise the awareness of horizontal violence in nursing so that practitioners come to understand how this in itself can be an expression of power. Drawing upon theories of reflective practice, the article examines how the educational system in nursing may have contributed to the felt oppression within the group by colluding with the cultural narrative. The crosscurrents of cultural narration are strong and it is argued here that the nurse needs to feel empowered in order to take action to swim against the tide. The author proposes that a model of transformatory learning based upon critical theory creates the possibility of emancipatory action in nursing, both locally and globally.

Patients continue to be physically restrained in psychiatric in-patient units. Studies concerned with staff-related variables have suggested that the emotional reactions of professionals to violent or potentially violent patients may influence their use of restrictive measures. However, no research existed that described psychiatric nurses' thoughts and feelings while they were involved in restraint situations nor what effects their thoughts and feelings had on their decision to restrain. Therefore, an ethnographic qualitative study was conducted in order to describe systematically nurses' thoughts and feelings toward restraint use in the in-patient psychiatric setting. The conceptual approach guiding the study was Etzioni's (1992) theoretical work on the role of normative-affective factors in decision making. Following ethical approval of the study, ethnographic interviews were conducted with six nurses from an in-patient psychiatric unit who had participated in a situation involving the physical restraint of a patient. The analysis of the nurses' thoughts and feelings revealed that the restraint situation represented a decision dilemma for them. This overall finding was supported by four themes: (1) the framing of the situation: the potential for imminent harm; (2) the unsuccessful search for alternatives to physical restraints; (3) the conflicted nurse; and (4) the contextual conditions of restraint. The results indicated that restraint use is more complex than is currently conveyed in the literature in that normative-affective factors influenced nurses' restraint decisions. The findings advance our understanding of why restraints continue to be used in psychiatric units. Further research is necessary to examine the findings in other settings and with a larger and more diverse population in order to draw definitive conclusions about the continued use of physical restraints in the care of patients on psychiatric units in hospitals.

In recent years nursing as a whole has moved from a position of apparently little manifest concern in the issue of 'clinical supervision' to a veritable explosion of interest which is beginning to find expression in the literature. Beginning with a discussion of clinical supervision from within a psychodynamically informed interpersonal nursing framework this paper reports on a small scale qualitative inquiry which aimed to explore mental health nurses' perceptions and experiences of clinical supervision. Analysis of data derived from a series of semi-structured interviews provides very encouraging early indications that mental health nurses are becoming better able to reflect upon the nature of their own formative learning needs and so to take seriously their need for professional support as they strive towards a more therapeutic relationship with their patients. However, whilst all of the participants in the study had a positive perception of the potential value of clinical supervision, there is clear evidence to suggest that their actual experience was that 'good enough supervision' was more the exception than the rule. The participants' perceptions and experiences are described and the implications for research, practice, education and the management of service delivery systems are outlined.

This research study adopts a phenomenological approach to investigate how a group of clinical nurse specialists think and experience their role. It reviews the literature on the clinical nurse specialist from 1943, when Frances Reiter first coined the phrase "nurse clinician', to the present time, when individuals are committed to a range of initiatives aimed at improving the quality of the British National Health Service and patient care. The study investigates and analyses their views and conveys the personal meaning of clinical nurse specialists' "lived experience' in the role. Findings of the study suggest that clinical nurse specialists are experienced practitioners who strive to be in positions in which they influence patient care and utilize advanced knowledge, expertise and leadership skills in a multidisciplinary environment. The literature proposes that for the role to be recognized and accepted individuals need to be educated at an advanced level, demonstrate practice based in research and have a firm base as a specialist in nursing. The findings clearly suggest that while the role of the clinical nurse specialist can be influenced in a positive manner by the organization and guided by the individual, it is important to acknowledge that the role is in a transitional phase. Finally, the research suggests the importance of establishing a clear role definition in a creative and supportive environment allowing for autonomy, professional growth and the development of individuals as clinically competent nurse specialists.

The purpose of this paper is to alert researchers and agency staff to potential conflicts that may arise during research projects conducted in busy community-based agencies. Within a framework of human territoriality, key factors in avoiding such conflicts are explored. Territoriality is the defence against intruders of an area of land which is considered to be owned. For humans, something owned includes space, objects, ideas, privileges or rights. Key territoriality concepts explored in the paper are: the private domain, encompassing a privacy retreat and personal space; and the public arena which includes psychological space and action territory. Examples of violation of the types of territory are examined and suggestions for prevention of conflicts are provided.

This paper reports on a cross-sectional survey that aimed to compare the role conception types and role discrepancy between 140 certificate and 81 degree nursing students in Hong Kong. Non-probability convenience sampling was used and the participants selected from the hospital-based training were first, third and fourth study block students. Second-, third- and fourth-year students from the degree programme were selected for comparison. The role conception scale developed by Pieta was modified and adopted to measure the role conception and discrepancy. ANOVA test was performed to examine differences across and within the two groups. The results showed that the degree students had a significantly higher ideal but lower actual professional role conception than the certificate students. An interaction effect between the groups (certificate--degree) and grades (stages of education) was detected in the ideal professional role, indicating a marked drop of the score for the fourth-year degree students. For the discrepancy role conception score, the degree students had a significantly higher discrepancy score in all the three role conception types compared with their certificate counterparts. In summary, the impact of the educational process on the development of role conception was demonstrated. Compared to the certificate students, the ward practice seemed to exert a far greater impact on degree students' role conception.

The purpose of this qualitative study was to describe the use of independent therapeutic nursing interventions by registered nurses in a variety of health care delivery agencies. The process used to integrate nursing interventions into the daily routines of agencies that did not formally require their use, the conditions in which they were implemented, and the consequences of their use, were examined. Data collection methods include observations and interviews of 36 participant nurses, employed in five health care agencies, for 1 year. The organizational culture of each environment was observed and its impact on the enactment of independent therapeutic nursing interventions was evaluated. Data analysis, done by using the constant comparative method, generated a proposal of a substantive theory that integrates conditions and consequences of therapeutic nursing intervention. Intra-role conflict, the product of incompatible expectations of the professional conception of nursing and task oriented/medically controlled work environments, served as the motivating force behind strategies of enactment utilized to overcome barriers to implement therapeutic nursing interventions. As a consequence of using therapeutic nursing interventions, participants perceived empowerment in relation to clients, peers and other health care professionals.

Aim To explore moral distress in relatives doctors and nurses, in end-of-life care decision-making, in the adult intensive care unit. Background Many deaths in intensive care involve decisions about withholding and withdrawing therapy, potentially triggering moral distress. Moral distress occurs when individuals feel constrained from acting in accordance with moral choice, or act against moral judgement, generating painful, unresolved emotions, and problems that continue long after an event. Prior research has focused mainly on nurses; less is known about doctors' experiences and occurrence and impact on relatives is unknown. Design A narrative inquiry case study approach, funded by a Northern Ireland Health and Social Care Doctorate Fellowship Award (April 2011). Methods In-depth digitally recorded interviews will be conducted with relatives, doctors, and nurses involved in end-of-life cases comprising: (1) withdrawal of therapy, including circulatory death organ donation; (2) non-escalation of therapy; and (3) brain stem death with a request for organ donation. Relatives will be offered the opportunity to share their experiences on ‘Healthtalkonline’ by copyrighting audio-visual interviews to the Health Experiences Research Group, Oxford University. Research Ethics Committee approval was obtained (April 2012). Discussion This is the first time that moral distress is explored, in a case approach, among relatives, doctors, and nurses intimately involved in end-of-life decisions in intensive care. Dissemination of findings will make a large contribution to international knowledge and understanding in this area and alert healthcare professionals and relatives to an otherwise under-recognized, but potentially detrimental, experience. Findings will inform education, practice, and policy.

This article is a report of the development and psychometric testing of the Stressor Scale for Clinical Research Coordinators.Job stress is viewed as a situation where working conditions interact with individual worker characteristics and result in disruption of psychological or physiological homeostasis. Clinical research coordinators, also known as research nurses, are professionals who play a central role in clinical trials. They face various problems associated with their responsibilities; however, few studies have reported on their stress. To manage their stress, it is necessary to identify the sources of stress (i.e. stressors).The 56-item preliminary instrument was developed based on literature review and expert discussions. A total of 589 clinical research coordinators in 186 hospitals in Japan were surveyed in 2011. Statistical analyses on construct and concurrent validity, internal consistency, and test-retest reliability were performed.A six-factor solution with 23 items was selected using exploratory factor analysis: 'quantitative workload', 'conflict with investigators', 'ambiguity of work', 'conflict with other clinical research coordinators and with supervisors', 'demands from an affiliate other than the hospital', and 'difficulty in caring for trial participants'. Confirmatory factor analysis affirmed construct validity, with a demonstrated acceptable fit between the factor structure and the observed data. All factors had significant correlations with burnout and psychological distress, which indicated acceptable concurrent validity. Cronbach's alpha coefficients ranged from 0·73-0·82. Intra-class correlation coefficients indicated almost satisfactory test- retest reliability.Our new instrument has acceptable validity and reliability for evaluating job stressors for clinical research coordinators.

This article reports the study of a group of United Kingdom health visitors' interactions with their changing practice context, focusing on role identity and influences on its stability.United Kingdom policies have urged health visitors to refocus their role as key public health nurses. Reduced role identity clarity precipitated the emergence of different models of health visiting public health work. An inconsistent role standard can lead to role identity fragmentation and conflict across a group. It may precipitate individual role crisis, affecting optimum role performance.Seventeen health visitors in two United Kingdom community healthcare organizations participated in a grounded theory study, incorporating constant comparative analysis. Direct observations and individual interviews were undertaken between 2002 and 2008.Four interlinked categories emerged: professional role identity (core category); professional role in action; interprofessional working; and local micro-systems for practice; each influencing participants' sense of identity and self-worth. The Role Identity Equilibrium Process explains interactive processes occurring at different levels of participants' practice.Re-establishing equilibrium and consistency in health visiting identity is a priority. This study's findings have significance for other nurses and health professionals working in complex systems, affected by role change and challenges to role identity.

The purpose of the study was to examine what kind of effect a relative with chronic pain had on his or her partner and the other members of the family. The methodology used was grounded theory. The sample was a convenience group of 18 chronic pain sufferers, their partners, and one adult child taken from two pain clinics. The subjects were briefed on the purpose of the study, and how their confidentiality would be protected. Informed consent was then obtained. Data were collected through audio-taped interviews, which were conducted on an individual basis in the subject's home environment. Analysis was conducted through the constant comparative method. Findings revealed that two main variables emerged, that of social relationships and coping techniques. The aspects of social relationships affected were the marital partnership, sexual activity, contact with friends and relatives, and roles. This meant that chronic pain caused social isolation, role tension, marital conflict, reduced sexual activity and feelings of anger, anxiety, resentment and despondency in other family members. However, the results also suggested that the extent to which chronic pain negatively affected the chronic pain sufferer's respective partner and other family members was dependent to some extent on how effective the family was in coping with a relative with chronic pain.

This article explores how cancer nurses experienced the threat of patients' mortality on malignant haematology units of one institution in Ontario, Canada.Although patients with cancer are living longer with bone marrow transplantations, still they face possibilities of dying due to complications from treatment and their disease.Interpretive phenomenology guided the process. Nineteen front-line registered nurses were purposively recruited from two inpatient bone marrow transplant units. Focused observations and individual interviews were analysed. Data were collected from April to August 2007.The major findings emphasized nurses' internal conflict related to their simultaneous need to help patients fight their disease and to prepare them for the possibility of letting go. The authors used the terms 'letting go', not to reflect nurses' intents to abandon life but to release patients from perceived norms of the 'curative culture'. Nurses experienced 'bursting the bubble of hope' by circumstances not in their control, and were often not certain whether or not to respond and how to respond to the distress of patients and families about death and dying. When feeling reassured of meeting patients' and families' expectations, nurses enabled patients and families to let go when further treatment was futile, prevented technological intrusions, and helped patients have 'easier' deaths.Results suggest enhancing nurses' capacity to negotiate more effectively the contradictory clinical tasks of fighting disease and preparing patients for the end of life. In this regard, nurses may minimize patients' distress by providing opportunities for them to share their fears and have them validated.

To describe surgical nurses' perceived levels of ethical dilemmas, moral distress and perceived quality of care and the associations among them.Nurses are committed to providing quality care. They can experience ethical dilemmas and moral distress while providing patient care. Little research has focused on the effect of moral distress or ethical dilemmas on perceived quality of care.Descriptive, cross-sectional study.After administration and institutional Research Ethics Committee approval, a researcher requested 119 surgical nurses working in two Israeli hospitals to fill out three questionnaires (personal background characteristics; Ethical Dilemmas in Nursing and Quality of Nursing Care). Data collection took place from August 2007 to January 2008.Participant mean age was 39·7 years. The sample consisted mostly of women, Jewish and married staff nurses. The majority of nurses reported low to moderate levels of ethical dilemma frequency but intermediate levels of ethical dilemma intensity. Frequency of ethical dilemmas was negatively correlated with level of nursing skill, meeting patient's needs and total quality of care. No important correlations were found between intensity of ethical dilemmas and quality of care.Levels of ethical dilemma frequency were higher than intensity. Nurses tended to be satisfied with their level of quality of care. Increased frequency of ethical dilemmas was associated with some aspects of perceived quality of care.Quality of care is related to ethical dilemmas and moral distress among surgical nurses. Therefore, efforts should be made to decrease the frequency of these feelings to improve the quality of patient care.

This article is a report of a Neuman Systems Model-guided correlational study of the relations of stress resiliency, psychological empowerment, selected demographic characteristics (age, ethnicity, semester in school) and conflict management styles.Emerging evidence suggests that stress resiliency and psychological empowerment can strengthen student nurses in academic achievement and coping with stress. Little is known about conflict management styles of students and the relationship to empowerment, resiliency and the implications for managing workplace conflict.A correlational study was conducted in Spring 2010 with 166 baccalaureate students. Most participants were female, single, Hispanic and 25 years old. The data collection instruments included the Stress Resiliency Profile, the Psychological Empowerment Instrument, the Conflict Mode Instrument and a demographic inventory. Descriptive and inferential correlational statistics were used to analyse the data.Students scored in the high range for focusing on their deficiencies in conflict situations; they scored above the 60th percentile for avoiding and accommodating behaviours and were less likely to use competing or collaborating strategies to manage conflict. Empowerment scores were significantly correlated with stress resiliency scores. Students with high scores on empowerment had high scores on the skill recognition subscale of the Stress Resiliency Profile suggesting more resilience; high scores on empowerment were related to high necessitating subscale scores of the Stress Resiliency Profile suggesting a predisposition to stress.Neuman Systems Model may provide guidance for educators to strengthen student nurses' management of stressors in the workplace.

We examined the Decisional Conflict Scale to determine if it would be useful to measure conflict around sports participation decision-making in youth with cardiac pacemakers and/or implantable cardioverter defibrillators.Sports participation decisions made by parents and youth with implanted cardiac devices can have profound implications. Contact sports can result in damage to the device and leads, but the value of exercise is well documented and restriction from a cherished activity can increase resistance and distress in the young. The extent of this problem is unknown.An explanatory mixed methods design was used with a convenience sample (N=35) of youth aged 12-21 (Mean=16.5; sd=3) years awaiting services at an electrophysiology clinic. Data were collected between 2007 and 2008. The Decisional Conflict Scale is a self-report measure, used worldwide in adult populations. Analyses and interviews determined the properties of the measure and whether the instrument captured conflict.The scale showed strong internal consistency (Cronbach alpha=0.87). Overall scores were low (Mean=17.31; SD=10.99; range=0-37). There was no statistically significant difference (P0.05) in total scores between boys (n=25) and girls (n=10) using independent t-tests. Qualitative analysis documented conflict and non-adherence to clinician recommendation despite low scores.Analyses indicate that youth aged 12-21 years understand and can effectively complete the Decisional Conflict Scale, but this instrument alone did not capture all conflict. These results can guide study of the extent of this problem and eventual development of an intervention to support sports participation decision-making.

Nursing is a manifestation of a value according to which it is morally good to promote physical and psychological well-being. Such a moral obligation involves making judgements. Ethical judgements are the decisions a person makes on whether a particular act is right or wrong. Ethical principles serve as the basis for ethical rules and as a framework for decision-making. Ethical theory provides a rationale that explains the principles and rules in order to provide a structured approach to ethical reasoning. Although ethics is not a science with verifiable answers, a knowledge of ethical theory enables nurses to make decisions in a manner that is more comprehensive and well reasoned than is opinion or intuition. In this paper, an overview of ethical theories, ethical principles and influences on ethical or moral reasoning is presented as well as the ethical decision-making process.

Fourteen experienced nurses participated in an explorative study aimed at describing the experiential aspects of moral decision making in psychiatric nursing practice. In-depth interviews were conducted according to the grounded theory method. These were transcribed, coded and categorized in order to generate conceptual categories. The concept of benevolence was identified as a central motivating factor in the nurses' own accounts of situations in which decisions were made on behalf of the patient. This seems to conceptualize the nurses' expressed aim to do that which is 'good' for the patient in responding to his or her vulnerability. This study indicates the need for further research into the subjective, experiential aspect of ethical decision making from a contextual perspective.

This paper is a report of a study that examined the effects of work demands, including employment status, work inflexibility and difficulty reconciling work and family caregiving, on role strain and depressive symptoms of adult-child family caregivers of older people with dementia.Family caregivers also employed for pay are known to be affected by work demands, i.e. excessive workload and time pressures. However, few studies have shown how these work demands and reconciliation between work and family caregiving influence caregivers' role strain and depressive symptoms.For this cross-sectional study, secondary data were analysed for 119 adult-child family caregivers of older people with dementia in Taiwan using hierarchical multiple regression.After adjusting for demographic characteristics, resources and role demands overload, family caregivers with full-time jobs (β=0.25, P0.01) and more difficulty reconciling work and caregiving roles (β=0.36, P0.01) reported significantly more role strain than family caregivers working part-time or unemployed. Family caregivers with more work inflexibility reported more depressive symptoms (β=0.29, P0.05).Work demands affected family caregivers' role strain and depressive symptoms. Working full-time and having more difficulty reconciling work and caregiving roles predicted role strain; work inflexibility predicted depressive symptoms. These results can help clinicians identify high-risk groups for role strain and depression. Nurses need to assess family caregivers for work flexibility when screening for high-risk groups and encourage them to reconcile working with family-care responsibilities to reduce role strain.

This paper is a report of a study of patterns of perceptions of conscience, stress of conscience and burnout in relation to occupational belonging among Registered Nurses and nursing assistants in municipal residential care of older people.Stress and burnout among healthcare personnel and experiences of ethical difficulties are associated with troubled conscience. In elder care the experience of a troubled conscience seems to be connected to occupational role, but little is known about how Registered Nurses and nursing assistants perceive their conscience, stress of conscience and burnout.Results of previous analyses of data collected in 2003, where 50 Registered Nurses and 96 nursing assistants completed the Perceptions of Conscience Questionnaire, Stress of Conscience Questionnaire and Maslach Burnout Inventory, led to a request for further analysis. In this study Partial Least Square Regression was used to detect statistical predictive patterns.Perceptions of conscience and stress of conscience explained 41.9% of the variance in occupational belonging. A statistical predictive pattern for Registered Nurses was stress of conscience in relation to falling short of expectations and demands and to perception of conscience as demanding sensitivity. A statistical predictive pattern for nursing assistants was perceptions that conscience is an authority and an asset in their work. Burnout did not contribute to the explained variance in occupational belonging.Both occupational groups viewed conscience as an asset and not a burden. Registered Nurses seemed to exhibit sensitivity to expectations and demands and nursing assistants used their conscience as a source of guidance in their work. Structured group supervision with personnel from different occupations is needed so that staff can gain better understanding about their own occupational situation as well as the situation of other occupational groups.

This paper is a report of a secondary analysis of the experiences of employed breastfeeding mothers.Health promotion policies exhort mothers to feed their infants breastmilk exclusively for the first 6 months and partially until the age of 2 years. More mothers are returning to paid employment less than a year after having a baby. Combining breastfeeding and paid work is an issue for nursing and midwifery as predominantly female professions caring for women and their children.Foucauldian discourse analysis was used for a secondary analysis of interviews performed in 2005 with 20 women who continued to breastfeed on their return to work. The discursive positions and disciplinary practices were identified and analysed.Combining breastfeeding and paid work required negotiating the positions of good mother and good worker. Being a good mother conferred health benefits on infants. Being a good worker required the mothers to constrain their breastfeeding practices. The practices performed by the mothers involved stockpiling breastmilk, maintaining milk supply, preparing the baby ready for absence, making sacrifices and remaining silent and invisible as a breastfeeding worker.Breastfeeding workers have the potential to threaten the focus of the workplace. They discipline themselves to minimize their disruptive potential. Such strategies serve to maintain the marginalization of breastfeeding in the workplace and to keep women's efforts to continue breastfeeding invisible. The work of breastfeeding workers needs to be better recognized and supported.

Community health nurses frequently face situations involving ethical conflicts, but little research has been carried out in this area. This paper, based on a study of dilemmas defined by 30 practising community health nurses in urban and rural British Columbia, Canada, presents an analysis of the situations that contain the most serious ethical conflicts for nurses working in the community. Although issues related to client's rights, nurses' interactions with colleagues and the system, and nurses' rights were explored, nurses in the study reported that situations involving high-risk parenting provided the most serious ethical challenges. Strategies to help nurses caring for such vulnerable clients are described. As well, this paper offers some discussion on implications for community health nursing practice and education in light of current changes and challenges.

Dilemmas are a part of nurse practice. In situations where a problem potentially has two or more unsatisfactory resolutions, the nurse chooses which course of action to take. The decision to choose constitutes a dilemma. This study focuses on the dilemmas faced by nurses in dialysis units and the context in which they occur. A qualitative design was employed, using open interviews with eight nurses currently employed in dialysis nursing. This approach was taken in order to explore and gain in-depth understanding of the dilemmas in practice. Analysis reveals that dilemmas encountered in dialysis nursing emerge from conflicts in relationships with other people in the work environment. The dilemmas relate to the nurses' perception of the limited power they have in the determination of their practice. This powerlessness is reinforced by their perceived and real isolation from nurses working outside their area of practice. Traditionally, literature on dilemmas in nursing has focused on the development of ethical frameworks to guide practice and the resolution of dilemmas. However, the findings of this study suggest that if nurses are to deal with dilemmas effectively, both for the nurse and the patient, there must be an examination of the structural constraints affecting their practice. Models that are employed by nurses to guide practice must account for the structural elements in the work environment.

Non-attendance at out-patient clinics is a persistent, worldwide problem. In contrast with previous research, a qualitative approach was used in this study to examine reasons for non-attendance at out-patient clinics in one Belfast hospital, by exploring perspectives of general practitioners (GPs), hospital staff and defaulters. Findings revealed conflicts of opinion between GPs and hospital staff on appropriate management of certain medical and postnatal patients. Patients' reasons for defaulting were wide-ranging; however, 32% of those interviewed did not attend, or were recorded as non-attenders, for reasons relating to inefficient hospital administration. It is concluded that the causes of non-attendance were multifactorial, and non-attenders could not be stereotyped as irresponsible. Suggested measures to alleviate the problem include discussion between groups of professionals on responsibility for care of medical and postnatal patients, increased negotiation between patients and physicians in order to develop agreed programmes of care, and, where possible, a shifting of the onus of responsibility for making and cancelling appointments onto patients.

The purpose of this paper is to describe the major issues from the literature which confront first-line nurse managers. The increasingly complex environment in which these managers function has, at the very least, significantly altered their role. However, there are other issues confronting those in first-line positions and these are discussed under four broad headings: the role of first-line nurse managers; role conflict and confusion; management skills and functions; and education for first-line nurse managers.

Conflict is recognized as being a common occurrence in both everyday personal and professional nursing life, and it is now generally agreed that conflict can be both problematic and potentially beneficial to both individuals and organizations. There is a large amount of anecdotal and narrative literature about the nature and sources of conflict which fails to reflect upon the complexities and theoretical perspectives that exist. There are also few research studies which examine the nature of nursing conflict and how conflict is managed by nurses in the workplace. This study presents a review of some aspects of conflict and its management and specifically investigates the conflict management style of staff nurses and nurse managers in the hospital setting. The results suggest that avoidance is the most commonly used conflict management strategy, with competition being the least favoured.

This paper presents a study of the particular dynamics within hospitals that act as counterproductive forces to caring. To this end, the insights revealed by Isabel Menzies Lyth, following her observations of a large London teaching hospital, will be explored. She argues that hospitals are environments conducive to the erection of primitive social defence systems that generate internal conflict and persecution anxiety within its staff. These social defence systems, in turn, militate against efforts directed towards caring. This results in feelings of guilt, depression and dependency that rapidly establish a negative cycle of affects. Such negative affections, once set in train, are difficult to terminate and transform into a positive cycle of affections. Following this analysis, it will be argued that the hospital environment is unequal to the task of caring for the caregivers because it is permeated with ontological, spiritual and moral anxiety, all of which act as serious impediments to the caring enterprise.

This review paper seeks to adopt a constructive approach towards the subject of the role conflict experienced by student nurses. The significance of role conflict is explored, as are its causes and its effects on the student. Role conflict is then discussed from the perspectives of social psychology in general and nursing in particular, and the paper concludes with an emphasis on the role of the nurse educator in helping the students deal actively and constructively with the role conflict that they will inevitably experience during their careers in nursing.

This paper considers the use of a rational curriculum planning model within nurse education. It suggests that the process of change within the model is oversimplified and mechanistic. As such it denies or ignores the experience of individuals involved in the change process by reducing their personal, cultural and political realities to a level of idealogical control. The unrestrained or unmodified application of a rational approach may, by this control, inhibit the development of change arising from subjective experiences. It may further be viewed as a political strategy which benefits powerful groupings within the school thus institutionalizing this power and maintaining the status quo in terms of power and influence.

Title. Nurses’ responses to ethical dilemmas in nursing practice: meta-analysis. Aim. This paper is a report of a study to explore nurses’ responses to ethical dilemmas in daily nursing practice. Background. Concern about nurses’ ethical competence is growing. Most nurses perceived that there were barriers in their work environment to ethical practice, compromising their ability to perform ethically. Since most research focuses on contextual barriers to nurses’ ethical practice, little is known about how nurses involve themselves in ethical decision-making and action in daily care. Method. A meta-analysis of nurses’ ethical behaviour was conducted using data from nine studies in four countries (n = 1592 registered nurses). In all studies, the Ethical Behaviour Test was used to measure nurses’ ethical responses, based on an adapted version of Kohlberg’s theory of moral development. Data were analysed using random-intercept regression analysis. Findings. All groups, except the expert group, displayed a uniform pattern of conventional ethical reasoning and practice. When nurses were faced with ethical dilemmas, they tended to use conventions as their predominant decision-guiding criteria rather than patients’ personal needs and well-being. Conclusion. Conformist practice (following conventions rather than pursuing good for the patient) constitutes a major barrier for nurses to take the appropriate ethical actions, as creativity and critical reflection are absent. There is an urgent need to find ways to promote nurses’ ethical development from conventional to postconventional ethical practice. More research is needed to strengthen existing empirical evidence.