<p>The application of the LSS law and how the public organization (Municipality of Hudiksvall) later had to reform their organization to fit the new demands is the foundation to this master's thesis. An internal evaluation was performed due to this reorganisation process within the social care department (LSS unit). The aim was to investigate and evaluate if the reorganization resulted in a better working environment and if the work load (distribution of work) became more evenly divided between the different unit managing directors. The primary empirical information to this master's thesis is collected from that evaluation report. The main aim of this master’s thesis is to answer if the organisational choice between specialised or de-specialised working tasks has an effect (experienced and measured) on the level of stress among the unit managing directors. We have found that it is a question about moral stress rather than a question about stressed managing directors in general. In this thesis the definition of “moral stress” is the discrepancy between one persons ethical properties and the actions that person have to take due to appointed level of power and the responsibility that follows with this power. Our main recommendation is to find an organisational structure based on the premises of the LSS-law while at the same time attending to the problems of the more and more difficult working situation amongst the employees. This can be achieved by gaining approval for a new prioritizing order form the politicians, the clients, and the employees. Such a reformation process (Sw “omnormeringsprocess”) would imply less moral stress. If the managing directors have a basic employment as a generalist the working tasks will be more evenly divided amongst the employees. Teams of 5-7 employees that encompasses specially qualified generalist and that meets on a regular basis is essential to relieve pressure from colleagues. This is essential to be able to make the most out of the special knowledge of the directors. In the extension of this change the assistants should be included in the existing substitutes-pool and each assistant’s special competence should be clarified.</p>

The application of the LSS law and how the public organization (Municipality of Hudiksvall) later had to reform their organization to fit the new demands is the foundation to this master's thesis. An internal evaluation was performed due to this reorganisation process within the social care department (LSS unit). The aim was to investigate and evaluate if the reorganization resulted in a better working environment and if the work load (distribution of work) became more evenly divided between the different unit managing directors. The primary empirical information to this master's thesis is collected from that evaluation report. The main aim of this master’s thesis is to answer if the organisational choice between specialised or de-specialised working tasks has an effect (experienced and measured) on the level of stress among the unit managing directors. We have found that it is a question about moral stress rather than a question about stressed managing directors in general. In this thesis the definition of “moral stress” is the discrepancy between one persons ethical properties and the actions that person have to take due to appointed level of power and the responsibility that follows with this power. Our main recommendation is to find an organisational structure based on the premises of the LSS-law while at the same time attending to the problems of the more and more difficult working situation amongst the employees. This can be achieved by gaining approval for a new prioritizing order form the politicians, the clients, and the employees. Such a reformation process (Sw “omnormeringsprocess”) would imply less moral stress. If the managing directors have a basic employment as a generalist the working tasks will be more evenly divided amongst the employees. Teams of 5-7 employees that encompasses specially qualified generalist and that meets on a regular basis is essential to relieve pressure from colleagues. This is essential to be able to make the most out of the special knowledge of the directors. In the extension of this change the assistants should be included in the existing substitutes-pool and each assistant’s special competence should be clarified.

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The purpose of our study is to examine whether social welfare secretaries experience obstacles in work to do their tasks in a way that they, from their own values, thinks is right. And if so, what are the reactions and what strategies do they use to manage this. The study is based on a qualitative method. The data consist of interviews, with five social welfare secretaries, which all work in southern Sweden. The social welfare secretaries both work at a children- and youth department and at a social allowance department. The interview guide was constructed in relation to the essays main purpose, which consists of three main themes (obstacles, reactions and strategies). Previous researches that are made are based on nurses and their employment that often focusing on ethical decisions that results in moral stress. We have found one study that is focused on moral stress among social welfare secretaries. The result of our study showed that the social welfare secretaries we interviewed experienced obstacles in work to do their tasks in a way that they, from their own values, thought were right. The obstacles that the social worker secretaries experienced were the Law, the lack of time and the economy. The result of our study also showed that the social welfare secretaries reacted in different ways when they experienced the obstacles. The social worker secretaries in our study reacted with anxiety, negative stress- symptom and anger/frustration. The social welfare secretaries in the study also told us about what strategies they used to handle situations when they experienced obstacles in work to do their tasks in a way that they, from their own values thought were right. Some of these strategies the social welfare secretaries used were communication, displacement to the Law, loyalty and experience (which we construed as a strategy in a longer time of view).

Moralisk stress påverkar sjuksköterskan och kan ses som ett resultat av yttre faktorer. Det finns ett ökat krav på att sjuksköterskan ska klara av att hantera moraliskt, stressade situationer. Genom handledning kan sjuksköterskan få hjälp att verbalisera sina upplevelser. Syftet  är att belysa på vilket sätt omvårdnadshandledning kan bidra till att sjuksköterskan kan hantera den moraliska stressen med fokus på omvårdnadshandledningens struktur och innehåll. En litteraturstudie har genomförts där tio artiklar granskats och analyserats. För att få en förståelse för omvårdnadshandledning har en teoretisk referensram om omvårdnadshandledningens uppbyggnad, struktur och innehåll används. Resultatet visar att handledning kan påverka sjuksköterskans och övrig vårdpersonals moraliska stress i både positiv och negativ riktning då den etiska kompetensen hos deltagarna ökar. Vidare framkommer det att personalen ibland väljer kamratstöd istället för organiserad handledning. Etisk kompetens kan stärkas genom handledning och öka deltagarens förmåga till eftertanke och reflektion. Detta kan dock leda till att sjuksköterskan hämmas att hantera situationer som innefattar etiska problem, då hon eller han blir allt för kritisk i sitt förhållningssätt. Det finns dock anledning att anta att handledning stärker sjuksköterskans beslutskapacitet och självförtoende att handla i etiskt svåra situationer. / Moral stress affects the nurse and can be seen as a result of external factors. There is a growing demand that the nurse should be able to handle moral stressful situations. Through clinical supervision the nurse may be helped to verbalize her experiences. The aim of this study is to illustrate the way in which clinical supervision can help the nurse to deal with moral stress, focusing on the structure and content of clinical supervision. A literature study has been conducted. Ten articles have been reviewed and analyzed. To create an understanding for clinical supervision a theoretical framework has been used focusing on the structure and content of clinical supervision. The results show that the clinical supervision may affect the nursing staff’s moral stress, in both a positive and negative way, when the ethical competence of participants increases. Furthermore, it appears that staff sometimes chooses to turn to colleagues for support instead of organized clinical supervision. Ethical competence may increase through clinical supervision when increasing the participant's ability to reflect upon an ethical situation. However, this can harm the nurses’ ability to deal with future situations involving ethical issues when seeing a situation from a critical approach. Supervision, however, strengthens the nurses’ decision-making capacity and strengthens her confidence to act in ethically difficult situations.

Bakgrund: Moralisk stress är ett begrepp som först kom att definieras av Jameton (1984) och anses uppstå när sjuksköterskor inte kan handla i enlighet med det de anser vara det rätta på grund av organisatoriska eller institutionella barriärer. Den legitimerade sjuksköterskan ansvarar för ett stort kunskaps- och arbetsområde som ska präglas av ett etiskt förhållningssätt och en personcentrerad vård. En inre konflikt uppstår när sjuksköterskan hindras att arbeta utifrån de rådande värdena, vilket ger upphov till känslor av moralisk stress. En större kunskap och förståelse inom problemområdet är nödvändig för att åstadkomma framtida förbättringar. Syfte: Syftet var att belysa moralisk stress hos sjuksköterskan. Metod: För att uppnå syftet har en litteraturöversikt genomförts. Sökningar efter relevanta artiklar i enlighet med den engelska översättningen av moralisk stress utfördes. Artiklar med kvalitativa och kvantitativa ansatser har använts. Resultat: Ur analysen urskildes tre olika huvudkategorier: bakomliggande orsaker till moralisk stress, konsekvenser av moralisk stress och strategier för hantering av moralisk stress. Diskussion: I resultatdiskussionen diskuteras moralisk stress hos sjuksköterskor utifrån Jean Watsons teori om mänsklig omsorg samt andra relevanta artiklar. Uppkomsten av moralisk stress hos sjuksköterskor diskuteras ur olika perspektiv. Skillnader i miljö och ledningens betydande roll avseende sjuksköterskors känslor av moralisk stress diskuteras vidare. Konsekvenser av moralisk stress hos sjuksköterskor diskuteras med betoning på patientsäkerhet och bemötandet av patienter. Medvetenheten kring moralisk stress hos sjuksköterskor behöver bli större. Ett fokus på moralisk stress hos sjuksköterskor kan med fördel lyftas redan under sjuksköterskeutbildningen. / Background: Moral stress is a term that was first defined by Jameton (1984) and is considered to occur when individuals are unable to act in accordance with what they consider to be right due to organizational or institutional barriers. The registered nurse is responsible for a large area of knowledge and work that needs to be characterized by an ethical approach and person-centered care. An internal conflict occurs when the nurse is prevented from working on the basis of these values, which causes feelings of moral stress. A greater knowledge and understanding of the problem area is necessary to achieve future improvements. Aim: The aim was to illustrate moral stress among the nurse. Method: To achieve this goal, a literature review has been conducted. Searches for relevant articles in accordance with the English translation of moral stress were performed. The databases Cinahl, PsycINFO and PubMed were used. Articles with qualitative and quantitative approaches have been used. Results: The analysis revealed three different main categories: underlying causes for moral stress, consequences of moral stress and strategies for managing moral stress. Discussion: In the result, moral stress is discussed among nurses based on Jean Watson's theory of human care and other relevant articles. The appearance of moral stress in nurses is discussed from different perspectives. Differences in the environment and management's significant role regarding nurses' feelings of moral stress are discussed further. The consequences of moral stress in nurses are discussed with emphasis on patient safety and the encounter of patients. Awareness about moral stress in nurses needs to be greater. A focus on moral stress in nurses should be emphasized during nursing education.

Bakgrund: Det ställs inre och yttre krav på sjuksköterskor som i sin yrkesroll måste göra medvetna val. Valen skall baseras på individuell vård för varje patient, vara rättssäkra och samtidigt vara effektiva för såväl avdelningen som organisationen. Kraven som ställs på sjuksköterskor kan utgöra en psykisk påfrestning som kan yttra sig i form av moralisk stress. Moralisk stress är de känslor och upplevelser som utgörs av en moralisk motsättning, där personen i fråga vet vilken handling som är korrekt men blir begränsad att utföra den på grund av organisatoriska, strukturella och ekonomiska faktorer. Moralisk stress grundar sig i det fysiologiska fenomenet stress som är kroppens överlevnadsreaktion vid yttre belastning i form av stressorer. För att upprätthålla en god och säker omvårdnad ska sjuksköterskor följa olika styrande riktlinjer och förordningar inom hälso- och sjukvård. Syfte: Belysa sjuksköterskors erfarenheter av moralisk stress. Metod: En litteraturstudie med elva kvalitativa artiklar som insamlats med hjälp av systematisk databassökning där datamaterial sedan granskades och analyserades. Goodmans sju-stegsmodell användes som stöd i metoden för att finna och bedöma relevant vetenskaplig litteratur. Resultat: Efter analys av datamaterial framkom fem teman: Bristande samverkan mellan yrkeskategorier, organisationen försvårar sjuksköterskans arbete, känsla av otillräcklighet, känslomässiga reaktioner och ökat kollegialt stöd. Konklusion: Moralisk stress är globalt förekommande bland sjuksköterskor som uttrycker olika erfarenheter kring fenomenet. Bristande samverkan mellan läkare och sjuksköterskor i kombination med organisatoriska svårigheter leder till en känsla av otillräcklighet för sjuksköterskor. / Background: There are internal and external demands on nurses who must make conscious choices. The choices must be based on individual care for each patient, be legally secure and at the same time be effective for both the ward and the organization. The demands set on nurses can become a psychological distress that can be seen as an internal conflict in the form of moral stress. Moral stress are the feelings and experiences that consist of a moral contradiction, where the person know the correct way to act but is limited to execute it because of organizational, structural and economic factors. Moral stress is based on the physiological phenomenon of stress, which is the body's survival reaction to external burden in the form of stressors. There are various controlling factors and guidelines that nurses should follow in healthcare in order to maintain a good and safe care. Objective: To illuminate nurses’ experience of moral stress.Method: A literature review of eleven qualitative studies that were generated by systematic database search and then reviewed and analysed. To support the method Goodman’s seven-step model was used to find and assess the relevant scientific literature.Results: After analysing data five themes were revealed: Lack of collaboration between professionals, organization that complicate nurses’ work, feelings of inadequacy, emotional reactions and increased support from colleagues. Conclusion: Moral stress is a globally occurring phenomenon which nurses’ express a variety of different experiences. Lack of collaboration between physicians and nurses combined with organizational difficulties leading to a feeling of inadequacy for nurses.

The purpose of this study was to gain a greater understanding of potential challenges from a moral stress perspective that Swedish military leaders can face when implementing autonomous weapons systems. Two questions were asked to investigate this: what demands may arise and how can leaders be impacted? The study was conducted as a literature study and data from nine peer reviewed articles and a research report from the Swedish Defense Research Institute were analyzed via thematic analysis. The result seems to show that the lack of control, the lack of trust and difficulty in demanding responsibility from an autonomous weapon system creates moral leadership challenges. Without control over the autonomous weapon system, the consequences of its actions risk going against the leader's moral and this creates problems with how leadership can and should be conducted. The study also seems to show that autonomous weapon systems can lead to a moral impact on leaders, since autonomous weapon systems risk leading to increased distancing and risking contributing to increased violence. Given the moral leadership challenges and the moral influence made visible in this study, there seems to be a great risk of moral stress and even moral injury if autonomous weapon systems are used for actions that go against the leader's morality.

Etiska aspekter av vårdyrket spelar inte en framträdande roll i sjuksköterskeutbildningen. Etik är den teoretiska referensramen för ett korrekt moraliskt handlande och sjukvård handlar om att ge rätt omvårdnad till en individ i behov av detta. När moraliska värderingar och verkligheten kolliderar kan en konflikt uppstå, vilket i sin tur kan leda till moralisk stress. Psykisk ohälsa har på senare tid ökat bland sjukvårdspersonal som en direkt följd av moralisk stress. Syftet med denna empiriska enkätstudie är att undersöka i vilken grad undersköterskor och sjuksköterskor upplever moralisk stress i det dagliga arbetet. Studien har utförts på en medicinklinik på UMAS där alla undersköterskor och sjuksköterskor på avdelningen har inkluderats. Ett modifierat validerat mätinstrument har används för att mäta vilka situationer som är särskilt känsliga för moralisk stress samt i vilken grad detta ger dåligt samvete. Resultatet visar att det förekommer moralisk stress på avdelningen. Det finns inte någon skillnad mellan yrkeskategorierna i förekomsten av de utvalda situationerna däremot finns det en signifikant skillnad i vissa situationen när det gäller graden av dåligt samvete. / Ethical aspects of health care profession do not take a prominent role in nursing programme. Ethics is the theoretical reference for proper moral behavior and healthcare is about providing the right care to an individual in need of it. When moral values and reality collide a conflict can arise, which in turn can lead to moral stress. Psychological illness has recently increased among healthcare professionals as a direct result of moral stress. The aim of this empirical survey is to examine to which degree staff nurses and nurses experiencing moral stress in their daily work. The study was conducted at a medical clinic at UMAS where all the staff nurses and nurses in the department were included. A modified validated questionnaire has been used to measure the situations that are particularly sensitive to moral stress and to which degree these situations give troubled conscience. The result indicates that moral stress exists in the department. There is no difference in the presence of the selected situations between staff nurses and nurses, however, there is a significant difference between staff nurses and nurses in some situations to which they contribute troubled conscience.

Sjuksköterskor har som uppgift att tillgodose patienters vårdbehov därav är det betydelsefullt att vara lyhörd och se varje patient som en unik person. Målet med hälso- och sjukvården är att tillgodose en god och säker vård till alla patienter. Sjuksköterskor ska värna om sin egen hälsa för att kunna bedriva en god vård vilken kan påverkas av stress. Hur stress bland sjuksköterskor kan påverka patientsäkerheten är betydelsefullt att belysa då det är av vikt att se hur påföljden blir för patienterna. Syftet med studien är att belysa sjuksköterskors upplevelser av hur arbetsrelaterad stress kan påverka patientsäkerheten inom hälso- och sjukvården. Den valda metoden är en litteraturöversikt som inkluderar 10 artiklar. Resultatet består av totalt 3 huvudteman och 6 underteman som belyser olika faktorer som kan påverka stressupplevelsen för sjuksköterskor och hur patienter blir påverkade av detta. Resultatet visar att stress är en individuell upplevelse och är ett vanligt förekommande problem bland sjuksköterskor. Stress på arbetsplatsen kan också medföra att sjuksköterskor får svårigheter med att upprätthålla en holistisk vård och tillgodose patienternas vårdbehov. Därutöver kan otillräckliga resurser, en bristande kommunikation och teamsamarbete medföra en försämrad vård för patienter och sjuksköterskors vilja att stanna kvar. Utifrån litteraturöversiktens resultat diskuteras det att stress kan medföra att sjuksköterskor begår misstag vilket kan påverka patienterna. Dessa negativa händelser kan medföra att sjuksköterskor upplever en moralisk stress då de förorsakat ett extra lidande för patienterna och därmed äventyrat patientsäkerheten. Med en ökad reflektion kan kunskapen utvecklas samt bidra till en ökad förståelse för hur rätt förutsättningar för sjuksköterskor kan bidra till en patientsäker vård. / Nurses are tasked with meeting patients' care needs, therefore it is important to be responsive and see each patient as a unique person. The goal of healthcare is to provide good and safe care to all patients. Nurses must take care of their own health in order to provide good care, which can be affected by stress. How stress among nurses can affect patient safety is important to highlight as it is important to see how the consequences will be for the patients. The aim of the study is to illustrate nurses' experiences of how work-related stress can affect patient safety in healthcare. The chosen method is a literature review that includes 10 articles. The result consists of a total of 3 main themes and 6 sub-themes that highlight various factors that can affect the stress experience for nurses and how patients are affected by this. The results show that stress is an individual experience and is a common problem among nurses. Stress in the workplace can also mean that nurses have difficulties in maintaining holistic care and meeting patients' care needs. In addition, insufficient resources, a lack of communication and teamwork can lead to a deterioration in patient care and nurses' willingness to stay. Based on the results of the literature review, it is discussed that stress can cause nurses to make mistakes, which can affect patients. These negative events can mean that nurses experience moral stress as they have caused extra suffering for the patients and thus endangered patient safety. With increased reflection, knowledge can be developed and contribute to an increased understanding of how the right conditions for nurses can contribute to a care with high patient-safety.