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To map and describe in the international literature the ethical conflicts experienced by nurse managers and to identify the strategies used in resolving ethical conflicts by nurse managers

Uvod: Etični konflikt predstavlja resen poklicni problem. Medicinske sestre so na svojem delovnem mestu čedalje bolj obremenjene, še posebej v intenzivnih enotah, kjer je delo z življenjsko ogroženimi pacienti posebej težavno in je pojavnost etičnih konfliktov toliko večja. Namen je bil ugotoviti stopnjo izpostavljenosti etičnim konfliktom med medicinskimi sestrami v intenzivni enoti.Metode: Izvedena je bila kvantitativna presečna opazovalna raziskava. Vanjo je bilo vključenih 97 medicinskih sester, zaposlenih v intenzivnih enotah ene bolnišnice. Podatki so bili zbrani s pomočjo vprašalnika in statistično obdelani z uporabo univariatne statistike.Rezultati: Raziskava je pokazala, da so medicinske sestre v intenzivnih enotah zmerno izpostavljene etičnim konfliktom (x = 138,85, s = 89,08). Najpogosteje doživljajo etični konflikt ob situacijah, ko primanjkuje virov,ki zdravstvenemu timu omogočajo upoštevanje etičnih smernic za delovanje (x = 14,11, s = 9,13). Najmanj so izpostavljene etičnim konfliktom, ko je treba v okviru kliničnega preizkušanja dajati zdravila in pri tem ne prejmejo vseh potrebnih informacij, ki so po njihovem mnenju potrebne za izvajanje te naloge (x = 2,25, s = 3,70).Diskusija in zaključek: Pri pojavnosti stopnje etičnega konflikta pri medicinskih sestrah je bilo ugotovljeno, da se srečujejo s konflikti, ki so rahlo problematični in precej problematični. Največji etični konflikt se pojavi pri pomanjkanju časa za upoštevanje etičnih smernic za delovanje, kar kaže, da je medicinskih sester premalo za kakovostno oskrbo pacientov.

Background:Ethical conflict and subsequent nurse moral distress and burnout are common in the intensive care unit (ICU). There is a gap in our understanding of nurses’ perceptions of how organizational resources support them in addressing ethical conflict in the intensive care unit.Research question/objectives/methods:The aim of this qualitative, descriptive study was to explore how nurses experience ethical conflict and use organizational resources to support them as they address ethical conflict in their practice.Participants and research context:Responses to two open-ended questions were collected from critical care nurses working in five intensive care units at a large, academic medical center in the Midwestern region of the United States.Ethical considerations:This study was approved by the Institutional Review Board at the organization where the study took place.Findings:Three main interwoven themes emerged: nurses perceive (1) intensive care unit culture, practices, and organizational priorities contribute to patient suffering; (2) nurses are marginalized during ethical conflict in the intensive care unit; and (3) organizational resources have the potential to reduce nurse moral distress. Nurses identified ethics education, interprofessional dialogue, and greater involvement of nurses as important strategies to improve the management of ethical conflict.Discussion:Ethical conflict related to healthcare system challenges is intrinsic in the daily practice of critical care nurses. Nurses want to be engaged in discussions about their perspectives on ethical conflict and play an active role in addressing ethical conflict in their practice. Organizational resources that support nurses are vital to the resolution of ethical conflict.Conclusion:These findings can inform the development of interventions that aim to proactively and comprehensively address ethical conflict in the intensive care unit to reduce nurse moral distress and improve the delivery of patient and family care.

Background: During the Covid-19 pandemic, nurses experienced increased pressure. Consequently, ethical concerns and psychological distress emerged. This study aimed to assess nurses’ ethical conflict, resilience and psychological impact, and compare these variables between nurses who worked in Covid-19 wards and nurses who did not. Methods: Design—Multicentre online survey. Setting—Multi-site public hospital, all nursing staff were invited to participate. The survey included validated tools and a novel instrument to assess ethical conflict. Spearman’s rho coefficient was used to assess correlations between ethical conflict and psychological distress, logistic regressions to evaluate relationships between nurses’ characteristics and outcome variables, and the Mann–Whitney/t-test to compare groups. Results: 548 questionnaires out of 2039 were returned (275 = Covid-19, 273 = non-Covid-19). We found a low–moderate level of ethical conflict (median = 111.5 [76–152]), which emerged mostly for seeing patients dying alone. A moderate and significant positive correlation emerged between ethical conflict and psychological distress rs (546) = 0.453, p &lt, 0.001. Nurses working in Covid-19-ICUs (OR = 7.18, 95%CI = 3.96–13.01, p &lt, 0.001) and Covid-19 wards (OR = 5.85, 95%CI = 3.56–9.6, 0.001) showed higher ethical conflict. Resilience was a protective factor for ethical conflict. Conclusions: Ethical conflict was significantly linked to psychological distress, while a higher level of resilience was found to be a protective factor. These results can be informative for nursing management in future similar crises.

BackgroundEthical conflicts are common in the critical care setting, and have compromised job satisfaction and nursing care quality. Using reliable and valid instruments to measure the ethical conflict is essential. This study aimed to translate the Ethical Conflict in Nursing Questionnaire — Critical Care Version into Chinese and determine the reliability and validity in the population of Chinese nurses.MethodsResearchers obtained permission and followed the translation-backward method to develop the Chinese version of the Ethical Conflict in Nursing Questionnaire — Critical Care Version (ECNQ-CCV-C). Relevant psychometric properties were selected according to the Consensus-based standards for the selection of health status measurement instruments checklist. Critical care nurses were recruited from two tertiary public hospitals in Hangzhou, Zhejiang Province, and Kunming, Yunnan Province. Of the 264 nurses we approached, 248 gave their consent and completed the study.ResultsThe ECNQ-CCV-C achieved Cronbach’s alphas 0.902 and McDonald’s omega coefficient 0.903. The test-retest reliability was satisfactory within a 2-week interval (intraclass correlation coefficient = 0.757). A unidimensional structure of the ECNQ-CCV-C was determined. Confirmatory factor analysis supported acceptable structure validity. Concurrent validity was confirmed by a moderate relation with a measure for hospital ethical climate (r = − 0.33,p ConclusionsThe ECNQ-CCV-C demonstrated acceptable reliability and validity among Chinese nurses and had great clinical utility in critical care nursing.

Background: A growing body of evidence about nurses’ ethical conflicts has been added to nursing science in recent decades, but no research has been done in Estonia. Ethical conflicts are a cultural and context sensitive phenomenon, so the historical, legal, social, economic and political backgrounds and position of nursing have had an impact on ethical conflict experiences. Aim: Describe nurses’ experiences of ethical conflicts. Method: A qualitative, descriptive study was conducted among nurses (n = 21) in May-October 2018 in Estonia. The data were collected in the form of semi-structured individual interviews and analysed using the inductive content analysis method. Ethical considerations: Due to the sensitive nature of the research topic, only individual interviews were carried out. Findings: Nurses’ ethical conflicts were related to situations that violated the rights, safety or well-being of the patient or relatives, caused them suffering, were against their will or threatened nurses’ dignity and professionalism through a variety of practices, attitudes and relationships. The insufficiency of patient care and professional collaboration emerged as important sources of nurses’ ethical conflicts and were connected to historical and societal factors. Conclusions: In order to achieve good quality of care, nurses need to have appropriate education and organisational support to carry out ethical daily care. More research is needed to understand the multidimensional cultural and contextual knowledge of ethics and nurses’ ethical conflicts.

Ethical conflicts among nurses can undermine nurses&rsquo, psychological comfort and compromise the quality of patient care. In the last decade, several empirical studies on the phenomena related to ethical conflicts, such as ethical dilemmas, issues, problems, difficulties, or challenges, have been reported, however, they have not always deeply explored the meaning of ethical conflicts experienced by nurses in geriatric care. This study aims to understand the lived experiences of ethical conflict of nurses in geriatric hospitals in South Korea. A phenomenological study was conducted. In-depth, face-to-face interviews were performed with nine registered nurses who cared for elderly patients in geriatric hospitals in South Korea between August 2015 and January 2016. Three main themes emerged from the analysis: (1) confusing values for good nursing, (2) distress resulting from not taking required action despite knowing about a problem, and (3) avoiding ethical conflicts as a last resort. It was found that for geriatric nurses to cope with ethical conflicts successfully, clear ethical guidance, continuing ethics education to improve ethical knowledge and moral behaviors, and a supportive system or program to resolve ethical conflicts involving nurses should be established.

This study aimed to identify and investigate the main characteristics of the top 100 most cited studies on conflict in published in nursing category in the Web of Science database using bibliometric and social network analysis methods.A retrospective bibliometric analysis was used.The study data were obtained from the Web of Science (WoS) database. The top 100 studies with the highest number of citations were included in the study. The study data were analysed with Excel and SPSS and they were visualized with VOSviewer.It was concluded that the studies in the research were published in 38 different journals between 1974-2019 and they were conducted by 245 different authors from 24 different countries. It was further reported that the Journal of Advanced Nursing was the most productive journal and the USA was the most productive country. The most commonly used keywords were "nurse," "conflict," "nursing," "job satisfaction," "work-family conflict" and "ethical conflict."The issue of conflict is a growing field of scientific study for nursing researchers. The quality of researches will be certainly enhanced in future with the studies published in journals with high impact factors.The research of the top 100 most cited paper is a new and innovative bibliometric approach to understand nursing literature. There is very little information about the development, structure and characteristics of the existing mass of knowledge on conflict in nursing studies. The study findings establish a basis of information for planning further studies and providing guidance. In addition, this study provides researchers, scientific journals, institutions and countries with an opportunity to assess and compare their own performance in conflict literature in nursing studies. However, the fact that the most cited studies in the field of conflict in nursing is in demand by journals with high impact factor is a source of motivation for researchers studying in this field.目标: 本研究采用文献计量学和社交网络分析方法，对科学网数据库中护理类文献中被引用最多的100项冲突研究的主要特征进行识别和调查。 设计: 使用回顾性文献计量分析。 方法: 研究数据来自科学网（WoS）数据库。本研究包括被引用次数最多的前100项研究。研究数据用Excel和SPSS进行分析，并用VOSviewer进行可视化。 结果：: 结论是，该研究的在1974-2019年间发表在38种不同的期刊上，由来自24个国家的245位作者进行。另据报道，《高级护理杂志》是最多产的杂志，而美国是最多产的国家。最常用的关键词是“护士”、“冲突”、“护理”“工作满意度”、“工作家庭冲突”和“伦理冲突”。 结论: 对于护理研究人员而言，冲突问题是科学研究领域中一个日益增长的领域。随着在具有高影响因子的期刊上发表研究成果，研究质量一定会进一步提高。 影响: 对被引用最多的100篇论文的研究是理解文献的一种新颖且创新的文献计量方法。在护理研究中，有关冲突的现有知识的发展、结构和特征方面的信息很少。研究结果为计划进一步研究和提供指导奠定了信息基础。此外，这项研究还为研究人员、科学期刊、机构和国家提供了一个机会，来评估和比较自己在护理研究中冲突文献中的表现。但是，高影响因子的期刊需要在护理冲突领域中被引用最多的研究，这为该领域的研究人员提供了动力。.

Introduction: Ethical conflict is a phenomenon that has been under study over the last three decades, especially the types moral dilemma and moral distress in the field of nursing care. However, ethical problems and their idiosyncrasies need to be further explored. Aim: The objectives of this study were, first, to obtain a transcultural Portuguese-language adaptation and validation of the Ethical Conflict Nursing Questionnaire–Critical Care Version and, second, to analyse Portuguese critical care nurses’ level of exposure to ethical conflict and its characteristics. Methods: A cross-cultural validation and descriptive, prospective and correlational study. The sample was made for 184 critical care nurses in 2016. Ethical Considerations: The study was authorised by Bioethics Commission of the University of Barcelona, the Associaçâo de Apoio ao Serviço de Cuidados Intensivos do Centro Hospitalar do Porto and the Sociedade Portuguesa de Enfermagem de Saúde Mental. Findings: The Portuguese version of the Ethical Conflict Nursing Questionnaire–Critical Care Version was a valid and reliable instrument to measure exposure to conflict. Moral outrage was the most common type of conflict. The most problematic situations were the ineffectiveness of analgesic treatments, the administration of treatments considered futile and the mismanagement of resources.

Background:Ethical conflict is a barrier to decision-making process and is a problem derived from ethical responsibilities that nurses assume with care. Intensive care unit nurses are potentially exposed to this phenomenon. A deep study of the phenomenon can help prevent and treat it.Objectives:This study was aimed at determining the frequency, degree, level of exposure, and type of ethical conflict among nurses working in the intensive care units.Research design:This was a descriptive cross-sectional research.Participants and research context:In total, 382 nurses working in the intensive care units in Iranian hospitals were selected using the random sampling method. Data were collected using the Ethical Conflict in Nursing Questionnaire-Critical Care Version (Persian version).Ethical considerations:This study was approved by the Medical Research Ethics Committee. Ethical considerations such as completing the informed consent form, ensuring confidentiality of information, and voluntary participation were observed.Findings:The results showed that the average level of exposure to ethical conflict was 164.39 ± 79.06. The most frequent conflict was related to “using resources despite believing in its futility,” with the frequency of at least once a week or a month (68.6%, n = 262). The most conflictive situation was violation of privacy (76.9%, n = 294). However, the level of exposure to ethical conflict according to the theoretical model followed was the situation of “working with incompetent staff.” The most frequently observed type of conflict was moral dilemma.Conclusion:The moderate level of exposure to ethical conflict was consistent with the results of previous studies. However, the frequency, degree, and type of ethical conflict were different compared to the results of other studies. Recognizing ethical conflict among intensive care unit nurses can be useful as it allows to consolidate those measures that favor low levels of ethical conflict, design appropriate strategies to prevent ethical conflicts, and improve the nursing work environment.

Ethical decision making is critically important in hospice social work. Through in-depth interviews, researchers explored ethical dilemmas faced by 14 hospice social workers and the processes they used to move toward resolution. The dilemmas were integrated into a framework focused on the sources of ethical conflict: the client system, the agency, and the profession. Processes involved in resolving ethical dilemmas included consulting with other professionals, weighing the pros and cons of options, and bringing about desired outcomes. Findings suggest that hospice teams should be provided with opportunities to meaningfully discuss ethical decision making. Further, the involvement of social workers in administrative leadership is recommended to increase the likelihood that discipline-specific perspectives are incorporated into formal policies and procedures that shape practice in ethically complex situations.

Background:Decision-making and assessment in emergency situations are complex and result many times in ethical conflicts between different healthcare professionals.Aim:To analyse and describe situations that can generate ethical conflict among nurses working in emergency situations.Methods:Qualitative analysis. A total of 16 emergency nurses took part in interviews and a focus group.Ethical considerations:Organisational approval by the University Hospital, and informed consent and confidentiality were ensured before conducting the research.Result/conclusion:Two categories emerged: one in ‘ethical issues’ and one in ‘emotions and feelings in caring’. The four ethical subcategories are presented: Autonomy, the first sub category: first, the nurse’s ability to practise care on an emergency ward and, second, to support the patient and/or relatives in terms of care and medical treatment. The conflicts arise when the nurse ends up in the middle between the patient and the physician responsible for the diagnosis and treatment from a nature scientific perspective. Reification of injured body: patient was often reified and fragmented, becoming just a leg or arm. Different factors contributed in this perspective. Pain: pain relief was often inadequate but more effectively treated in the emergency medical services than at the emergency department. The nurses highlighted the phenomenon of suffering because they felt that pain was only an object, forgetting the patients’ care need, like separating mind from body. Death: the nurses felt that the emergency services are only prepared to save lives and not to take care of the needs of patients with ‘end-of-life’ care. Another issue was the lack of ethical guidelines during a cardiac arrest. Resuscitation often continues without asking about the patient’s ‘previous wishes’ in terms of resuscitation or not. In these situations, the nurses describe an ethical conflict with the physician in performing their role as the patient’s advocate. The nurses express feelings of distress, suffering, anger and helplessness.

Cesarean delivery is the most common and important surgical intervention in obstetric practice. Ethics provides essential guidance to obstetricians for offering, recommending, recommending against, and performing cesarean delivery. This chapter provides an ethical framework based on the professional responsibility model of obstetric ethics. This framework is then used to address two especially ethically challenging clinical topics in cesarean delivery: patient-choice cesarean delivery and trial of labor after cesarean delivery. This chapter emphasizes a preventive ethics approach, designed to prevent ethical conflict in clinical practice. To achieve this goal, a preventive ethics approach uses the informed consent process to offer cesarean delivery as a medically reasonable alternative to vaginal delivery, to recommend cesarean delivery, and to recommend against cesarean delivery. The limited role of shared decision making is also described. The professional responsibility model of obstetric ethics guides this multi-faceted preventive ethics approach.

This study examined the association of nurses’ ethical conflict with hospitals with organizational commitment, stress, turnover intention, absence and turnover. Participants were 410 nurses working at four different Canadian hospitals. A longitudinal design was used where nurses completed a questionnaire to capture ethical conflict, stress and organizational commitment, and one year later, measures of turnover intention, absence and actual turnover were obtained for the same sample. We found three aspects of nurses’ ethical conflict with hospitals: patient care values, value of nurses, and staffing policy values. Our findings showed that all three aspects of nurses’ ethical conflict are associated with stress and patient care values is associated with actual turnover. We also found that staffing policy values is predictive of turnover intention, and that patient care values is predictive of absenteeism. Thus, our findings show the multidimensionality of nurses’ ethical conflict with hospitals. Further implications of our findings for practice and theory are discussed.

Nurses and physicians may experience ethical conflict when there is a difference between their own values, their professional values or the values of their organization. The distribution of limited health care resources can be a major source of ethical conflict. Relatively few studies have examined nurses' and physicians' ethical conflict with organizations. This study examined the research question ‘What are the organizational ethical conflicts that hospital nurses and physicians experience in their practice?’ We interviewed 34 registered nurses, 10 nurse managers, and 31 physicians as part of a larger study, and asked them to describe their ethical conflicts with organizations. Through content analysis, we identified themes of nurses' and physicians' ethical conflict with organizations and compared the themes for nurses with those for physicians.

Objectives Many natural health products and dietary supplements are purchased in pharmacies and it has been argued that pharmacists are in the best position to provide patients with evidence-based information about them. This study was designed to identify how the pharmacist's role with respect to natural health products and dietary supplements is portrayed in the literature. Method A systematic search was conducted in a variety of health databases to identify all literature that pertained to both pharmacy and natural health products and dietary supplements. Of the 786 articles identified, 665 were broad-coded and 259 were subjected to in-depth qualitative content analysis for emergent themes. Key findings Overwhelmingly, support for the sale of natural health products and dietary supplements in pharmacies is strong. Additionally, a role for pharmacist counselling is underscored. But another recurrent theme is that pharmacists are ill-equipped to counsel patients about these products that are available on their shelves. This situation has led some to question the ethics of pharmacists selling natural health products and dietary supplements and to highlight the existence of an ethical conflict stemming from the profit-motive associated with sales of natural health products and dietary supplements. Conclusions This analysis raises concerns about the ethics of natural health products and dietary supplements being sold in pharmacies, and about pharmacists being expected to provide counselling about products of which they have little knowledge.

Currently, the Ebola virus has been classified by the WHO as “an international public health emergency” that has highlighted among other things, the enormous importance of proper and timely medical care. However, the complexity of this new health scenario, mainly due to personal risk in the event of infection, means that professionals are directly faced with situations of great ethical conflict since there is a competition between their duties to patients, colleagues, society and those directed to their own safety. The reasons given by those professionals who respond positively to the duties of their patients have been categorized into three items, namely: professional ethics, the need to help and work ethics. The philosophical foundations of these responses find their roots in the compassion and sense of responsibility that arise when we face helplessness.

Objective: The main objective of this study was to identify and classify the most common ethical conflicts faced by health professionals working in outpatient and inpatient services. Material and method: a) Expert opinions gathered through semistructured meetings; b) opinions gathered through a questionnaire distributed after a presentation by an ethics committee in health and social services’ centers; and c) an exploratory study with 4 focus groups in which distinct professionals with recognized experience from home and hospital care services participated. Results: The most frequent conflicts faced by health and social services professionals, most of which were common to outpatient and inpatient care, concerned the relationship among health professionals, the appropriateness of therapeutic activities, the relationship with the patient’s family, respect for patients’ preferences, and conflicts arising from the management of social resources and organizational issues. Conclusions: Identifying ethical conflicts through exploratory studies allows topics likely to pose ethical dilemmas to be differentiated in a specific therapeutic area such as healthcare. The presence of one type of ethical conflict or another depends on the type of healthcare provided.

An exploratory study investigated ethical conflicts over access to services for elderly patients and social work practice activities within the context of the Medicare Prospective Payment System (PPS) in home health care. Questionnaires (n = 77) were distributed to attendees at the annual conference of the American Network of Home Health Care Social Workers in October, 2001 (response rate = 43%). A majority of the respondents rated the impact of the ethical conflict on elderly patients as “somewhat” or “very” negative. A decrease in the number of social work home visits since the implementation of PPS was reported by 63% of respondents. Implications for practice, education, and research are discussed.

Resumen: Introducción: La atrofia muscular espinal tipo 1 (AME-1) suele ser mortal en el primer año de vida sin soporte ventilatorio. La decisión de iniciar dicho soporte o no supone un conflicto ético para los profesionales sanitarios. Material y métodos: Se incluyó un escenario de fracaso respiratorio agudo en un lactante con AME-1 en un programa de formación mediante simulación avanzada para pediatras de atención primaria (PAP). Se analizaron de forma sistemática las actuaciones de 34 grupos de 4 pediatras que participaron en 17 cursos. Se valoraron los aspectos clínicos, éticos y de comunicación con los padres. Resultados: La asistencia técnica inicial (administración de oxígeno y soporte ventilatorio inmediato) fue realizada correctamente por el 94% de los equipos. Sin embargo, los PAP tuvieron problemas al abordar los aspectos éticos del caso. Del 85% de los equipos que plantearon el conflicto ético a los padres, lo hizo por iniciativa propia el 29%, el 23% los excluyó de forma activa y solo el 6% los implicaron y tuvieron en cuenta su opinión en la toma de decisiones. Solo el 11,7% preguntó por la calidad de vida del niño y el 12% por su conocimiento del pronóstico de la enfermedad. Ninguno les explicó las alternativas de tratamiento ni trató de contactar con el pediatra de referencia. Conclusiones: Ante un caso simulado de AME-1, los PAP tienen dificultades para interactuar con la familia e implicarla en la toma de decisiones. La formación práctica de todos los pediatras debería incluir problemas de ética clínica. Abstract: Introduction: Spinal muscular atrophy type 1 (SMA-1) tends to be fatal in the first year of life if there is no ventilatory support. The decision whether to start such support is an ethical conflict for healthcare professionals. Material and methods: A scenario of acute respiratory failure in an infant with SMA-1 has been included in a training program using advanced simulation for Primary Care pediatricians (PCP). The performances of 34 groups of 4 pediatricians, who participated in 17 courses, were systematically analyzed. Clinical, ethical and communication aspects with parents were evaluated. Results: The initial technical assistance (Administration of oxygen and immediate ventilatory support) was correctly performed by 94% of the teams. However, the PCP had problems in dealing with the ethical aspects of the case. Of the 85% of the teams that raised the ethical conflict with parents, 29% did so on their own initiative, 23% actively excluded them, and only 6% involved them and took their opinion into account in making decisions. Only 11.7% asked about the quality of life of children and 12% for their knowledge of the prognosis of the disease. None explained treatment alternatives, nor tried to contact the pediatrician responsible for the child. Conclusions: When faced with a simulated SMA-1 infant with respiratory failure, PCP have difficulties in interacting with the family, and to involve it in the decision making process. Practical training of all pediatricians should include case scenarios with an ethical clinical problem.

This study examined whether perioperative nurses (n = 40) were able to perceive and identify selected ethical issues occurring within their practice setting. The nurses described ethical conflicts and identified factors influential to their ethical decision making. The issues reported were organized into five categories: consent/advocacy, impaired provider/potential for unsafe practice, misrepresentation by care provider, disrespect for patient, and provider judgment/competency. The results of this study support that perioperative nurses both perceive and identify specific ethical issues in the surgical environment. Analysis of their reported actions revealed that the most common methods used for ethical conflict resolution were reporting to the immediate supervisor or personally confronting those directly involved.

Background: Ethical conflicts in nursing have generally been studied in terms of temporal frequency and the degree of conflict. This study presents a new perspective for examining ethical conflict in terms of the degree of exposure to conflict and its typology. Objectives: The aim was to examine the level of exposure to ethical conflict for professional nurses in critical care units and to analyze the relation between this level and the types of ethical conflict and moral states. Research design: This was a descriptive correlational study. Central and dispersion, normality tests, and analysis of variance were carried out. Participants and research context: A total of 203 nurses were from two third-level teaching hospitals in Spain. Both centers are part of the University of Barcelona Health Network. Participants filled out the Ethical Conflict in Nursing Questionnaire–Critical Care Version. Ethical considerations: This investigation received the approval of the ethical committees for clinical investigation of the two participating hospitals. Participants were informed of the authorship and aims of the study. Findings: The index of exposure to ethical conflict was [Formula: see text]. The situations involving analgesic treatment and end-of-life care were shown to be frequent sources of conflict. The types of ethical conflict and moral states generally arranged themselves from lesser to greater levels of index of exposure to ethical conflict. Discussion: The moderate level of exposure to ethical conflict was consistent with other international studies. However, the situations related with family are infrequent, and this presents differences with previous research. The results suggest that there is a logical relationship between types of conflict and levels of exposure to ethical conflict. Conclusion: The types of ethical conflict and moral states were related with the levels of exposure to ethical conflict. The new perspective was shown to be useful for analyzing the phenomenon of ethical conflict in the nurse.

This article summarizes the body of research about ethical conflicts described by nurses in variousfields ofpractice and recommends direction for the use and extension of this information. Twenty-three studies that fit criteria for inclusion were located. As a group, studies use inconsistent terminology, pay little attention to measurement characteristics of the instruments used, and do not use explanatory theory about how and why ethical conflicts develop or are experienced. Several studies of nurses practicing in community and home care settings, in intensive care units, and in administrative roles show some common areas of ethical conflict. Studies of ethical conflicts can be used as a basis for improving practice.

Medical ethics and professionalism have come to play an increasingly important role in medical practice since the 1980s, but there still is widespread concern about unethical and unprofessional behavior. This survey, based on in-depth interviews held in 2001 with 31 internal medicine residents in 1 traditional and 1 primary care residency at Yale University, was intended to identify the work-related ethical conflicts experienced by these medical house officers. The interviews, which took 18 to 60 minutes, used a standardized guide with probes for clarification and additional detail. Without exception, the participants reported having uncomfortable, improper, unethical, or unprofessional experiences with patients. In 90% of cases, the respondent had been directly involved. These experiences were classified into 5 broad categories: 1) Telling the truth. Many ways of manipulating information were used to avoid telling patients the truth, including delaying or omitting information and, in some instances, lying. These behaviors were variably ascribed to pressure from attending physicians, families, peers, or patients themselves. Relevant topics were diagnoses, prognoses, and statements about how experienced residents were with specific procedures. 2) Respecting patients' wishes. Residents sometimes were unable to ensure that the patient's wishes were respected because of disagreement on the part of the medical team, the patient, or the family about what the patient truly wished and what was in the patient's best interest. 3) Preventing harm. Several residents were distressed by having to accept the risks inherent in needed treatments or procedures. Occasionally, there was concern about the risk arising from the resident's limited experience with a given procedure. 4) Managing the limits of one's competence. Some residents felt inadequately prepared to perform their duties and were uncertain of what to do about it. They often were concerned about how their attending physician, peers, and patients would perceive the situation. Some residents felt it necessary to act as if they were more experienced than they believed they actually were. Some had trouble acknowledging their shortcomings. 5) Addressing the performance of others that is perceived as inappropriate. Residents experienced conflict when they viewed a peer's or an attending physician's performance as inadequate or inappropriate. They were uncertain about whether to challenge, intervene, or report the behavior while at the same time being accepted and approved by their colleagues. Hopefully, the challenges faced by medical residents will lead to better education in ethics and professionalism. Ultimately, residents must learn when compromising ethical standards might be acceptable and when it is not.

Objective: To describe the ethical concept of the fetus as a patient and identify its implications for the deliberative practice of perinatal medicine.Methods: We describe secular medical ethics and its two fundamental principles, beneficence and respect for autonomy. We articulate the ethical concept of the fetus as a patient on the basis of the ethical principle of beneficence.Results: In the deliberative practice of perinatal medicine guided by the ethical concept of the fetus as a patient, the perinatologist should always identify and balance beneficence-based obligations to the fetal patient and beneficence-based and autonomy-based obligations to the pregnant patient. Directive counseling is appropriate when the fetus is a patient. Non-directive counseling is appropriate when the fetus is not a patient.Conclusion: Counseling pregnant women about the clinical management of their pregnancies should always identify and balance beneficence-based obligations to the fetal patient and beneficence-based and autonomy-based obligations to the pregnant patient.

Much of the literature on clinical ethical conflict has been specific to a specialty area or a particular patient group, as well as to a single profession. This study identifies themes of hospital nurses’ and physicians’ clinical ethical conflicts that cut across the spectrum of clinical specialty areas, and compares the themes identified by nurses with those identified by physicians. We interviewed 34 clinical nurses, 10 nurse managers and 31 physicians working at four different Canadian hospitals as part of a larger study on clinical ethics committees and nurses’ and physicians’ use of these committees. We describe nine themes of clinical ethical conflict that were common to both hospital nurses and physicians, and three themes that were specific to physicians. Following this, we suggest reasons for differences in nurses’ and physicians’ ethical conflicts and discuss implications for practice and research.

This article critically questions the commercialization of hospice care and the ethical concerns associated with the industry’s movement toward “market-driven medicine” at the end of life. For example, the article examines issues raised by an influx of for-profit hospice providers whose business model appears at its core to have an ethical conflict of interest between shareholders doing well and terminal patients dying well. Yet, empirical data analyzing the experience of patients across the hospice industry are limited, and general claims that end-of-life patient care is inferior among for-profit providers or even that their business practices are somehow unseemly when compared to nonprofit providers cannot be substantiated. In fact, non-profit providers are not immune to potentially conflicting concerns regarding financial viability (i.e., “no margin, no mission”). Given the limitations of existing empirical data and contrasting ideological commitments of for-profit versus non-profit providers, the questions raised by this article highlight important areas for reflection and further study. Policy makers and regulators are cautioned to keep ethical concerns in the fore as an increasingly commercialized hospice industry continues to emerge as a dominant component of the U.S. health care system. Both practitioners and researchers are encouraged to expand their efforts to better understand how business practices and commercial interests may compromise the death process of the patient and patient’s family – a process premised upon a philosophy and ethical tradition that earlier generations of hospice providers and proponents established as a trusted, end-of-life alternative.

The purpose of this ethnographic study was to explore, describe, and document the practice of a group of psychiatric community health nurses (CHNs), and to provide a forum through which their voices could be heard. Discovery of the nature of issues CHNs experience in an effort to meet the needs of patients with mental illness was the focus. The paper describes the ethical conflict experienced by many of these nurses who wanted to provide beneficial, high-quality care to patients with mental illness but encountered obstacles in practice. Insight into the difficulties nurses experience in applying an ethic of care in the context of administrative constraints, resulting from the strict regulatory mechanisms imposed by third party insurance payers is provided. The negative impact of increasingly stricter payment restrictions on nursing practice and on quality of care is exposed.

A survey of home health social workers (N = 51) explored the effects on patients of ethical conflicts over access to services. The findings suggest that patients were as likely to be discharged or not receive services as they were to receive the services without paying a fee. Social workers rated themselves as moderately influential in the resolution of the conflict. Their influence was significantly correlated with patients more often receiving services and less often being discharged. Social work influence was enhanced by recognition of professional expertise and/or through informal networking within the agency. Implications for practice and education are discussed.

The purpose of this article is to report what can be learned about nurses’ ethical conflicts by the systematic analysis of methodologically similar studies. Five studies were identified and analysed for: (1) the character of ethical conflicts experienced; (2) similarities and differences in how the conflicts were experienced and how they were resolved; and (3) ethical conflict themes underlying four specialty areas of nursing practice (diabetes education, paediatric nurse practitioner, rehabilitation and nephrology). The predominant character of the ethical conflicts was disagreement with the quality of medical care given to patients. A significant number of ethical conflicts were experienced as ‘moral distress’, the resolution of which was variable, depending on the specialty area of practice. Ethical conflict themes underlying the specialty areas included: differences in the definition of adequacy of care among professionals, the institution and society; differences in the philosophical orientations of nurses, physicians and other health professionals involved in patient care; a lack of respect for the knowledge and expertise of nurses in specialty practice; and difficulty in carrying out the nurse’s advocacy role for patients.

Critical care nurses face ethical issues every day in relation to end-of-life decisions. This article presents a case study involving the administration of a neuromuscular blocking agent prior to removing a patient from the respirator. The decision to use a paralyzing agent caused an ethical conflict between the nurse and physician. The article discusses ethical principles in relation to end-of-life decisions from the nurse, physician, and family's perspective. Whatever the belief, critical care nurses must consider the belief's of the patient and family while trying to maintain their own convictions.

Cost containment, as an essential part of current efforts to manage health care, has been examined thoroughly from the perspectives of finance and patient care. In this article, the ethics of cost containment are discussed from the vantage point of the health care provider. Cost-cutting initiatives, however necessary and sound, nevertheless may place anesthesiologists in situations of ethical conflict and ultimately interfere with their rights as workers and professionals. The anesthesiology community is encouraged to investigate the effect of cost-cutting measures on patients and physicians alike.

Forensic nurses often face a competing duty to patients and society. This article explores possible solutions to the ethical conflict.

Ethical conflicts reported by registered nurse/certified diabetes educators: a replication¶ The purpose of this study was to identify types of ethical conflicts reported by certified diabetes educators who are also registered nurses (RN/CDEs) and to examine their relationship with demographic, educational and practice setting variables. This study is a replication of an earlier pilot study. Ethical conflicts expressed by RN/CDEs in active practice in New York and Pennsylvania were analysed according to four themes. Disagreement with medical practice was by far the most dominant clinical context for the conflicts (61%), as it had been in the pilot study (75%). Participants believed that 32% of the ethical conflicts were resolved. Ethics committees and consultants were very rarely used. Of the relationships between the kinds of conflicts and their resolution, and demographic, educational and practice setting variables of the participants, only kind of position was significantly (P

The purpose of this study was to identify the types of ethical conflict reported by certified registered rehabilitation nurses (CRRNs) and their relationship to demographic, educational, and practice-setting variables. Ethical conflicts expressed by CRRNs in active practice in Maryland, Virginia, and the District of Columbia were analyzed according to four themes. Disagreements about medical or institutional practice, patients' rights, and payment issues were the most frequent practice contexts for ethical conflicts, reflecting these nurses' considerable underlying concerns about resource allocation in rehabilitation practice. Participants believed that 60% of the ethical conflicts were resolved, frequently through discussions with other team members and patients' family members. Ethics committees and consultants were used infrequently. There were no statistically significant relationships between the kinds of conflicts or their resolution and the participants' demographic, educational, and practice-setting variables.

Objectives. To analyse the ethical implications of informing patients about their do-not-resuscitate status (DNR). Design. Questionnaire. Setting. Nationwide, 6 months after the publication of guidelines on DNR in 1994. Subjects. A 10% random sample of the members of the Swedish Cardiac Society, 104 physicians and 196 nurses. Main outcome measures. To what extent are patients, physicians and nurses involved in decisions about DNR, and how should the ethical conflict involved in informing patients about their DNR status be described and analysed? Results. Of 73% responding, 84% of the physicians and 8% of the nurses had made a DNR decision. The decision was regarded as ethically right and well timed and it was discussed with 33% of the competent patients. Half of the respondents believed that DNR orders should be discussed with the competent patient, but still only one third of the patients are involved. The ethical conflict is analysed using the principles of autonomy and nonmaleficence as value premises. Conclusions. Many physicians are still reluctant to find out what the patient wants. Being ignorant they risk harming the patient. It is recommended that information about DNR status should be given incrementally and that the attitudes of the old and chronically ill in-hospital patients are studied. Do they want to be informed, and if so, how and when do they want it to be done?