Sammanfattning   Bakgrund Skolsköterskan träffar alla barn under skolgången vid minst tre planerade tillfällen för hälsobesök. Tillsammans med andra professioner i skolan har skolsköterskan möjlighet att identifiera barn som far illa och har lagstadgad anmälningsplikt. Vid misstanke om samt anmälan av barn som far illa finns det risk för att skolsköterskor utsätts för stress och kan uppleva olika etiska dilemman. Detta gör det angeläget att ta reda på deras erfarenheter inom området. Syfte Att beskriva skolsköterskors erfarenheter av etiska dilemman vid misstanke om att barn far illa samt anmälan därav. Metod Studien genomfördes i två kommuner i sydsverige. Materialet samlades in vid elva intervjuer med skolsköterskor och analyserades med kvalitativ manifest innehållsanalys. Resultat De etiska dilemman som skolsköterskorna upplevde kategoriserades i fyra kategorier och elva underkategorier. Att bygga upp och bevara förtroendefulla relationer med barnen och föräldrarna var viktigt för skolsköterskorna. Viljan att göra rätt upplevdes som en svår uppgift eftersom det innebar att identifiera barn som far illa, att göra sin plikt, men även att göra nytta och inte skada. Skolsköterskorna kunde känna sig ensamma och utsatta i sin profession samt i behov av stöd, både från kollegor men även från andra professioner. De saknade återkoppling från socialtjänsten och önskade att de hade ett bättre samarbete. Slutsats Skolsköterskorna upplevde etiska dilemman i mötet med barn som far illa samt vid lagstadgad anmälan. Handledning, stöd under hela processen samt bättre samarbete med socialtjänsten skulle kunna leda till fler anmälningar. Utbildning samt standardiserade bedömningsinstrument bör kunna medföra att fler barn som far illa identifieras.   Nyckelord Skolsköterskor, barn som far illa, etiska dilemman, anmälningsskyldighet / Abstract Background The school nurse sees all children at least three times during their school years in connection to planned health visits. Together with other school professionals the nurse has the possibility to identify maltreated children and is obligated by law to report it. Suspecting and reporting child maltreatment might implicate an exposure to stress and dealing with various ethical dilemmas. It is therefore important to investigate the school nurses’ experiences concerning this issue. Aim To describe the school nurses’ experiences of ethical dilemmas when suspecting and reporting child maltreatment. Method The study was conducted in two counties in southern Sweden. Data was collected by interviewing eleven school nurses and analyzed by using a qualitative manifest content analysis. Results The ethical dilemmas experienced by the school nurses were categorized in four categories and eleven subcategories. Building and maintaining trustful relationships with the children and their parents was important for the school nurses. The wish to do right was experienced as difficult since it meant to identify maltreated children, to report it, and at the same do good and do no harm. The school nurses felt alone and vulnerable in this situation and needed support both from colleagues and other professionals. They lacked feedback from the child protection services and were yearning for a better collaboration. Conclusion The school nurses experienced ethical dilemmas when meeting maltreated children and being obligated to report it. Supervision, support during the process and a better teamwork with the child protection services may increase the reporting rate. Education and standard assessment instruments might increase the number of identified maltreated children.   Keywords School nurses, child maltreatment, ethical dilemmas, mandatory reporting

In the introductory part, the thesis deals with the description of terms such as senior, old age and basic physical and mental changes that accompany this period. In the next part of the work is characterized the term client, social worker and outlined the possibilities of social work legislation in the Czech Republic. In the third part of the thesis describes in detail terms such as ethics, ethical conduct, professional ethics, code of ethics, ethical dilemmas and supervision. Based on a written questionnaire and subsequent interview, the following chapter describes the ethical dilemmas of the six social services workers. Furthermore, this chapter describes ethically and problematic situations when working with seniors, which the workers in social services formulated as ethical dilemmas. This part of the thesis is followed by another chapter in which the analysis of the selected dilemmatic situation is performed and an insight into the solution of a particular dilemmatic situation using three ethical theories (deontology, utilitarianism and care ethics) is provided.

The diploma thesis deals with the description of terms such as senior, old age and basic physical and psychological changes that accompany this period. The next part of the thesis describes the concept of client, social worker and the possibilities of social work legislation in the Czech Republic. In the third part the thesis describes in detail the terms such as ethics, ethical behavior, professional ethics, ethical code and ethical dilemmas. The following chapter, based on a written questionnaire, describes the view of the ethical dilemmas of six female social workers. Furthermore, in this chapter, I present 13 selected dilemma situations that are based on the direct practice of female social workers. This part of the thesis is followed by another chapter, in which the analysis of the selected dilemma situation is carried out and a preview of the various ethical theories most frequently encountered in the literature. The ethical theories chosen are deontology, utilitarianism and ethics of care. The aim of this thesis was to describe the basic concepts of ethical dilemmas with which workers in social services can meet. The concrete practical solution of individual ethical situations by social service workers will enable a realistic view of solving ethical dilemmas in practice. The analysis of a particular selected dilemma situation will provide a view of solving this situation using the most important ethical approaches. Knowledge of these approaches can help social workers to make choices and choose the right ethical approach.

This study examined the conceptual framework of ethical reasoning of public elementary school assistant principals during decision-making. An ethical framework not only provides a descriptive way of thinking during ethical decision-making, but also provides a rationale for decisions. The purpose of this study was to determine which ethical reasoning framework, including the ethics of justice, critique, care, and the profession, elementary school assistant principals' use during decision-making. Additionally, the study determined other resources assistant principals' consult during decision-making. This study incorporated descriptive survey research through purposeful sampling with specific participant criteria. A researcher-developed survey of hypothetical dilemmas was deployed electronically to public elementary school assistant principals. Thirty-seven participants responded to four hypothetical scenarios, involving either staff or students, through a Likert scale and open response questions. Each hypothetical scenario included one of the ethical frameworks of justice, critique, care, or the profession embedded in one of four potential solutions. The findings suggest that elementary school assistant principals use an ethical framework during decision-making, whether they refer to the framework specifically by name or not. The data suggest the assistant principals in this study most frequently selected the ethic of care framework for their decision-making. Lastly, the evidence in this study suggests the most frequently consulted resource during decision-making by the assistant principals in this study was that of their principal. There is much research on ethics, teachers, and school leaders, but there are few studies on ethics and the assistant principal. Additionally, there are few studies on the assistant principal and ethical decision-making. The literature suggested that the assistant principalship is a stepping-stone to the principalship. If the assistant principalship is truly a stepping-stone for future principals, assistant principals need to have developed their personal and professional code of ethics, as well as, have an understanding of the ethical reasoning frameworks for implementation during ethical decision-making.

<p>I omvårdnaden av dementa uppstår ofta etiska överväganden där hänsyn skall tas till den demenssjuke, närstående, medboende samt lagar och riktlinjer. Sjuksköterskan ställs ofta inför svåra etiska situationer där beslut ska tas om eventuella tvångsåtgärder oberoende av vilket sorts stöd, moraliskt och/eller juridiskt, sjuksköterskan eventuellt har i sina beslut. Syftet med studien var att belysa sjuksköterskors upplevelser av etiska dilemman i demensvården i samband med olika tvångsåtgärder. Data samlades in via fokusgruppsintervjuer med sjuksköterskor (n=12) som ansvarade för personer med demenssjukdom inom särskilda boenden i en kommun i Norrland. En fallbeskrivning utgjorde grunden i fokusgruppsintervjuerna. Materialet analyserades via en kvalitativ manifest innehållsanalys. I resultatet framkom fyra kategorier. Etiska dilemman, etiskt förhållningssätt, rättsnormer och verklighet samt behov av stöd.  Sjuksköterskorna upplevde att de är ensamma i beslutsfattandet och behövde stöd i de svåra besluten kring åtgärder i olika etiska dilemman . Sjuksköterskorna upplevde närståendes delaktighet i vården av de dementa som ett bra och viktigt stöd och dialogen med närstående betonades. Det beskrevs också en känsla av stress då sjuksköterskan kommer i kläm mellan vårdpersonalens och de närståendes motstridiga krav som kan kännas svåra att tillmötesgå. En medvetenhet om de olika lagarna beskrevs men sjuksköterskorna upplevde det inte som ett etiskt dilemma att ibland behöva kringgå dem för att skydda den demente från skada eller lidande. Det skulle dock kännas bättre om de hade möjlighet att få stöd i lagen i sitt handlande. Den slutsats som vi drar är att sjuksköterskorna inte upplever några svårigheter att besluta om en tvångsåtgärd men behovet av stöd och handledning är stort.</p> / <p>Within the care of people with dementia ethical considerations often occurs and considerations has to be taken to the person with dementia, relatives, cohabitants and to laws and guidelines. Ethical dilemmas often occurs when the registered nurses (RNs) have to decide  whether or not to use constraints in the care, regardless of what kind of support these actions have in a moral or legal sense. The aim of this study was to describe the RNs experience of ethical dilemmas in relation to constraints in care of people with dementia. Data were collected in focus groups, with RNs (n=12) who worked in a municipal residential care for people with dementia in the north of Sweden. A case report initiated the interviews. Data were analyzed with qualitative content analysis. Four categories emerged. Ethical dilemmas, ethical approach, legal norms and reality, the need of support.  The RNs experienced loneliness in their decision making of interventions in different ethical difficult care situations and felt the need of support. They experienced that relatives are an important and a fine support in the care and the dialogue are pointed out as important. The RNs described feelings of stress when they were caught between conflicting demands from nursing staff and relatives. The RNs were aware of the laws related to health care, but they didn`t think of it as an ethical dilemma if they had to take sidestep from the law to protect the person with dementia from harm or misery. However they would feel better if they were supported by the law. <strong><em>Conclusion</em></strong><em>: </em>The RNs didn´t feel any difficulties if they had to decide to use constraints in the care of a person with dementia, but they are in need of support and coaching.</p>

<p>The meaning that Justice has after a conflict in a society might vary regarding the political development and cultural and shared values of a certain society.</p><p>Rawls, in his Theory of Justice gives his idea of what justice is and presents two principles of justice that he argues are required to live in a good society: a first principle that secures equal rights and liberties for all individuals and a second egalitarian principle that restrains the consequences of economic inequalities within societies. He also introduces the concept of “overlapping consensus” which I will use regarding the idea of Reconciliation, at the end of this paper.</p><p>In the cases presented in this paper (i.e. Argentina and South Africa), essential human rights were violated, therefore wrongdoers made the society unjust.</p><p>The aim of this thesis is to elucidate the conditions that are necessary to re-establish justice when a society goes through a conflict. I will introduce some ideas concerning that issue: ideas of retribution, reparation and reconciliation. These are seen as different paths for several countries when trying to tackle to the matter of achieving justice.</p><p>In my view, this question can be answered appealing first to an intuitive conception of moral justice that may exist at an individual and collective level, as well.</p><p>The ethical dilemmas both levels have are in relation to the harm done, punishments and how to balance them, limiting, for instance, the punishment in order to accomplish a just and a better society. I will also present how shared values can result from a process of reconciliation, which is considered as the ideal alternative to achieve justice.</p><p>However, when the equilibrium between members of a community is broken, some people claim that punishment can restore that lost equilibrium that existed before in the community.</p><p>Nevertheless, peace, reconciliation and justice cannot be constructed under the basis of silence. One way to keep memory alive is to let survivors, for instance, narrate what they have lived through; telling stories also creates a new space to share with others their experiences, revealing their fears and emotions. Regarding this theme, I will present the NUNCA MAS (Never Again) report, which is fundamental as it gives some testimonies, facts and proposals that will help to reach a consensus and therefore, future reconciliations.</p><p>Why is important to achieve justice? Because then members of a certain community will be able to interact in the present with common shared values and thus, deal with the past.</p><p>Not to consider reconciliation as one important step to achieve justice, and only think in terms of punishment, instead of giving way to peace and justice, could perhaps promote the possibility of further conflicts. To consider both punishment and reconciliation might just be one possible blueprint in the long and difficult way of searching for a just society.</p>

<p>The aim of the present literature study was to describe the significant factors contributing to the development of moral distress and the consequences of moral distress can lead to in the nurse profession. A literature search was performed in the databases Medline through PubMed and Academic Search Elite on the basis of in advanced defined criterions. A total of 19 articles was reviewed and included in the study. The main result revealed that nurses experience moral distress and that it is frequent within the nurse profession. The findings revealed that there seem to be several significant factors in the development of moral distress, such as providing life-sustaining care, competing loyalties, conflicts with the physician, communication barriers, emotional barriers, cultural barriers, regulation and rules and working environment that gives the nurse difficult or unsolved ethical dilemmas. The consequences of moral distress can contribute to health problems both physical symptoms and mentally, such as headache, neck and muscle pain, stomach problems, depression, anger and guilt. Moral distress affects the nurse professionally, and contributes to distancing from patients, relatives and colleagues, a resistance against going to work and to perform work tasks. The conclusion is that the consequences of moral distress don’t just affect nurses but undeniably also patients, relatives and other instances in within the healthcare system.</p> / <p>Syftet med denna litteraturstudie var att beskriva de faktorer som har betydelse för utvecklingen av moral distress, och vilka konsekvenser moral distress kan leda till i sjuksköterskans yrkesutövning. En litteratursökning genomfördes i databaserna Medline via PubMed och Academic Search Elite utifrån i förväg uppsatta kriterier. Totalt 19 artiklar granskades och inkluderades i studien. Huvudresultatet visade att moral distress existerar och är frekvent inom vården och sjuksköterskeyrket. Av författarnas resultat framkommer att det tycks finnas flera faktorer av betydelse för utvecklingen av moral distress, som livsuppehållande vård, konkurrerande lojaliteter, konflikt med läkaren, kommunikationshinder, emotionella hinder, kulturella hinder, föreskrifter och regler och arbetsmiljöfaktorer ger sjuksköterskan svårlösta eller olösta etiska och moraliska dilemman. Konsekvenserna av detta kan bidra till långvariga stressrelaterade hälsoproblem, så som huvudvärk, smärta i nacke, muskler och mage, nedstämdhet, ilska, skuld och depression. Moral distress får även konsekvenser för professionen så som avståndstagande till patienter, anhöriga och arbetskamrater, motstånd att gå till jobbet och att utföra sina arbetsuppgifter. Författarna drar slutsatsen att följderna av moral distress inte bara drabbar sjuksköterskan utan onekligen även patienter, anhöriga och övriga i vårdkedjan.</p>

The aim of the present literature study was to describe the significant factors contributing to the development of moral distress and the consequences of moral distress can lead to in the nurse profession. A literature search was performed in the databases Medline through PubMed and Academic Search Elite on the basis of in advanced defined criterions. A total of 19 articles was reviewed and included in the study. The main result revealed that nurses experience moral distress and that it is frequent within the nurse profession. The findings revealed that there seem to be several significant factors in the development of moral distress, such as providing life-sustaining care, competing loyalties, conflicts with the physician, communication barriers, emotional barriers, cultural barriers, regulation and rules and working environment that gives the nurse difficult or unsolved ethical dilemmas. The consequences of moral distress can contribute to health problems both physical symptoms and mentally, such as headache, neck and muscle pain, stomach problems, depression, anger and guilt. Moral distress affects the nurse professionally, and contributes to distancing from patients, relatives and colleagues, a resistance against going to work and to perform work tasks. The conclusion is that the consequences of moral distress don’t just affect nurses but undeniably also patients, relatives and other instances in within the healthcare system. / Syftet med denna litteraturstudie var att beskriva de faktorer som har betydelse för utvecklingen av moral distress, och vilka konsekvenser moral distress kan leda till i sjuksköterskans yrkesutövning. En litteratursökning genomfördes i databaserna Medline via PubMed och Academic Search Elite utifrån i förväg uppsatta kriterier. Totalt 19 artiklar granskades och inkluderades i studien. Huvudresultatet visade att moral distress existerar och är frekvent inom vården och sjuksköterskeyrket. Av författarnas resultat framkommer att det tycks finnas flera faktorer av betydelse för utvecklingen av moral distress, som livsuppehållande vård, konkurrerande lojaliteter, konflikt med läkaren, kommunikationshinder, emotionella hinder, kulturella hinder, föreskrifter och regler och arbetsmiljöfaktorer ger sjuksköterskan svårlösta eller olösta etiska och moraliska dilemman. Konsekvenserna av detta kan bidra till långvariga stressrelaterade hälsoproblem, så som huvudvärk, smärta i nacke, muskler och mage, nedstämdhet, ilska, skuld och depression. Moral distress får även konsekvenser för professionen så som avståndstagande till patienter, anhöriga och arbetskamrater, motstånd att gå till jobbet och att utföra sina arbetsuppgifter. Författarna drar slutsatsen att följderna av moral distress inte bara drabbar sjuksköterskan utan onekligen även patienter, anhöriga och övriga i vårdkedjan.

I omvårdnaden av dementa uppstår ofta etiska överväganden där hänsyn skall tas till den demenssjuke, närstående, medboende samt lagar och riktlinjer. Sjuksköterskan ställs ofta inför svåra etiska situationer där beslut ska tas om eventuella tvångsåtgärder oberoende av vilket sorts stöd, moraliskt och/eller juridiskt, sjuksköterskan eventuellt har i sina beslut. Syftet med studien var att belysa sjuksköterskors upplevelser av etiska dilemman i demensvården i samband med olika tvångsåtgärder. Data samlades in via fokusgruppsintervjuer med sjuksköterskor (n=12) som ansvarade för personer med demenssjukdom inom särskilda boenden i en kommun i Norrland. En fallbeskrivning utgjorde grunden i fokusgruppsintervjuerna. Materialet analyserades via en kvalitativ manifest innehållsanalys. I resultatet framkom fyra kategorier. Etiska dilemman, etiskt förhållningssätt, rättsnormer och verklighet samt behov av stöd.  Sjuksköterskorna upplevde att de är ensamma i beslutsfattandet och behövde stöd i de svåra besluten kring åtgärder i olika etiska dilemman . Sjuksköterskorna upplevde närståendes delaktighet i vården av de dementa som ett bra och viktigt stöd och dialogen med närstående betonades. Det beskrevs också en känsla av stress då sjuksköterskan kommer i kläm mellan vårdpersonalens och de närståendes motstridiga krav som kan kännas svåra att tillmötesgå. En medvetenhet om de olika lagarna beskrevs men sjuksköterskorna upplevde det inte som ett etiskt dilemma att ibland behöva kringgå dem för att skydda den demente från skada eller lidande. Det skulle dock kännas bättre om de hade möjlighet att få stöd i lagen i sitt handlande. Den slutsats som vi drar är att sjuksköterskorna inte upplever några svårigheter att besluta om en tvångsåtgärd men behovet av stöd och handledning är stort. / Within the care of people with dementia ethical considerations often occurs and considerations has to be taken to the person with dementia, relatives, cohabitants and to laws and guidelines. Ethical dilemmas often occurs when the registered nurses (RNs) have to decide  whether or not to use constraints in the care, regardless of what kind of support these actions have in a moral or legal sense. The aim of this study was to describe the RNs experience of ethical dilemmas in relation to constraints in care of people with dementia. Data were collected in focus groups, with RNs (n=12) who worked in a municipal residential care for people with dementia in the north of Sweden. A case report initiated the interviews. Data were analyzed with qualitative content analysis. Four categories emerged. Ethical dilemmas, ethical approach, legal norms and reality, the need of support.  The RNs experienced loneliness in their decision making of interventions in different ethical difficult care situations and felt the need of support. They experienced that relatives are an important and a fine support in the care and the dialogue are pointed out as important. The RNs described feelings of stress when they were caught between conflicting demands from nursing staff and relatives. The RNs were aware of the laws related to health care, but they didn`t think of it as an ethical dilemma if they had to take sidestep from the law to protect the person with dementia from harm or misery. However they would feel better if they were supported by the law. Conclusion: The RNs didn´t feel any difficulties if they had to decide to use constraints in the care of a person with dementia, but they are in need of support and coaching.

The meaning that Justice has after a conflict in a society might vary regarding the political development and cultural and shared values of a certain society. Rawls, in his Theory of Justice gives his idea of what justice is and presents two principles of justice that he argues are required to live in a good society: a first principle that secures equal rights and liberties for all individuals and a second egalitarian principle that restrains the consequences of economic inequalities within societies. He also introduces the concept of “overlapping consensus” which I will use regarding the idea of Reconciliation, at the end of this paper. In the cases presented in this paper (i.e. Argentina and South Africa), essential human rights were violated, therefore wrongdoers made the society unjust. The aim of this thesis is to elucidate the conditions that are necessary to re-establish justice when a society goes through a conflict. I will introduce some ideas concerning that issue: ideas of retribution, reparation and reconciliation. These are seen as different paths for several countries when trying to tackle to the matter of achieving justice. In my view, this question can be answered appealing first to an intuitive conception of moral justice that may exist at an individual and collective level, as well. The ethical dilemmas both levels have are in relation to the harm done, punishments and how to balance them, limiting, for instance, the punishment in order to accomplish a just and a better society. I will also present how shared values can result from a process of reconciliation, which is considered as the ideal alternative to achieve justice. However, when the equilibrium between members of a community is broken, some people claim that punishment can restore that lost equilibrium that existed before in the community. Nevertheless, peace, reconciliation and justice cannot be constructed under the basis of silence. One way to keep memory alive is to let survivors, for instance, narrate what they have lived through; telling stories also creates a new space to share with others their experiences, revealing their fears and emotions. Regarding this theme, I will present the NUNCA MAS (Never Again) report, which is fundamental as it gives some testimonies, facts and proposals that will help to reach a consensus and therefore, future reconciliations. Why is important to achieve justice? Because then members of a certain community will be able to interact in the present with common shared values and thus, deal with the past. Not to consider reconciliation as one important step to achieve justice, and only think in terms of punishment, instead of giving way to peace and justice, could perhaps promote the possibility of further conflicts. To consider both punishment and reconciliation might just be one possible blueprint in the long and difficult way of searching for a just society.