När individen upplever stress i samband med att inte kunna agera i enlighet med sitt samvete uppstår samvetsstress. Denna stress är vanligt förekommande hos sjuksköterskor. Om stressen blir långvarig kan den övergå till kronisk stress, vilket kan ge allvarliga konsekvenser. Syftet med denna studie var att beskriva när och hur sjuksköterskan upplever samvetsstress. Metoden var litteraturstudie som innefattade tio kvalitativa studier samt en kvantitativ studie som svarade på studiens syfte. Studierna söktes i databaserna CINAHL och MEDLINE. Resultatet redovisades i två teman med subteman. Tema 1 var orsak till samvetsstress med subteman brist på stöd, dåligt samarbete och tidsbrist. Tema 2 var beskrivning av upplevelsen av samvetsstress med subteman frustration, maktlöshet och otillräckligt och ensamhet. Slutsats Om sjuksköterskans förmåga att ge god omvårdnad äventyras kan patientsäkerheten riskeras. Genom att sjuksköterskan kräver mer stöd, respekt samt hjälp kan upplevelsen av samvetsstress minska. Klinisk betydelse Litteraturstudiens resultat kan leda till en ökad förståelse av vad som orsakar samvetsstress. / When the individual experience stress associated with not being able to act according to one’s conscience, stress of conscience occurs. This type of stress is common among nurses. If the stress becomes prolonged and becomes chronic it can lead to severe consequences. The aim of this study was to describe when and how nurses’ experience stress of conscience. The method used was a literature study which involved ten qualitative studies and one quantitative study that answered to the aim. The searches were made in the databases CINAHL and MEDLINE. The result was presented in two themes. Theme 1 was cause of stress of conscience with subthemes lack of support, bad cooperation and lack of time. Theme 2 was description of the experience of stress of conscience with subthemes frustration, powerlessness and inadequacy and loneliness. Conclusion If the nurses ability to provide good care compromises patients safety can be at risk. By demanding more support, respect and help the perception of stress of conscience can be reduced. Clinical significance The literature study’s result can lead to a better understanding of the causes stress of conscience.

Diss. (sammanfattning) Umeå : Univ., 2007. / Härtill 4 uppsatser.

Sjuksköterskans arbete, förhållningssätt och arbetsmiljö regleras i etiska koder, lagar och förordningar. Hen visar omsorg om patienten genom omvårdnad i dennes hela kontext. Trenden är att sjuksköterskan skall vårda personcentrerat och inte bara utföra uppgifter av teknologisk karaktär, det förstnämnda ställer krav på empati. En god omsorg och ett personcentrerat arbetssätt kan ses som en utmaning att hantera i sjuksköterskans arbetsmiljö. När sjuksköterskan inte klarar detta kan hen utveckla samvetsstress. Litteraturöversikten syftade till att beskriva upplevelsen av samvetsstress. Artikelsökning i databaser på termen compassion fatigue genomfördes och en blandning av kvalitativa och kvantitativa studier från Nordamerika, Kina och Portugal granskades. Totalt 12 artiklar samt en avhandling inkluderades i översikten. Resultatet delades in i tre huvudkategorier och totalt 14 subkategorier. Kategorierna besvarar frågeställningarna: faktorer som påverkar samvetsstress, symtom på samvetsstress och hur sjuksköterskor hanterar samvetsstress. Påverkansfaktorer var erfarenhet, förmåga till gränssättning, organisatoriska faktorer och svåra etiska frågeställningar. Symtomen var avskärmning, minskad tolerans, upplevelse av inkompetens och fysisk utmattning. Sjuksköterskan hanterar samvetsstress genom att prioritera sitt sociala liv, söka ledighet, byta patient, utbilda sig och byta arbete. I studier inom området råder en viss begreppsförvirring och olika forskare studerar och tolkar begreppen olika. Sjuksköterskor och organisationer har en begränsad kunskap om fenomenet. Bredden i funna studier bidrar med kunskapsunderlag om fenomenet samvetsstress. Utbildningsinsatser om fenomenet samvetsstress både inom utbildningsväsendet, för organisationen och sjuksköterskor i klinisk verksamhet är indicerat för att arbeta preventivt mot utveckling av samvetsstress.

I sjuksköterskans arbete ges omvårdnad till patienter där emotionella påfrestningar blir synliga för sjuksköterskan. När kraven blir större än vad sjuksköterskan klarar av samtidigt som hen är mottaglig för andra människors känslor uppkommer samvetsstress. Studiens syfte var att undersöka samvetsstress hos sjuksköterskan. Metoden i denna studie var en allmän litteraturstudie som innefattade 12 resultatartiklar. Resultatet resulterade i tre teman: bidragande faktorer, hälsoeffekter och förebyggande faktorer. Resultatet påvisade att en bristande arbetsmiljö och dåligt samvete är faktorer som generar samvetsstress och att sjuksköterskor har olika benägenhet att drabbas av samvetsstress beroende på sin bakgrund och sina erfarenheter. Samvetsstress går att förebygga genom att få stöd hemifrån, stöd ifrån organisationen och från arbetskollegor men även genom möjlighet till reflektion. En sjuksköterska som drabbas av samvetsstress får följder som påverkar privatlivet vilket slutligen kan leda till utbrändhet. Aktuell forskning om samvetsstress är otillräcklig. Ökade kunskaper och mer forskning inom området krävs för att minska detta relativt outforskade hälsoproblem. / In the nurse's work, care is given to patients where emotional strain become visible to the nurse. When the demands become larger than the nurse can manage while he or she is susceptible to other people's feelings, stress of conscience occurs. The aim of the study was to explore stress of conscience in the nurse. The method in this study was a general literature study that included 12 result articles. The result resulted in three themes: contributing factors, health effects and preventive factors. The result demonstrated that an insufficient working environment and bad conscience are factors that generate stress of conscience and that nurses have different tendency to be affected by stress of conscience, depending on their background and their experiences. Stress of conscience can be prevented by getting support from home, support from the organization and from colleagues, but also through the opportunity of reflection. The nurse which are affected by stress of conscience will have consequences that affect his/her private life which eventually can lead to burnout. Present research on stress of conscience is insufficient. Increased knowledge and additional research on the subject is required to lessen this relatively unexplored health problem.

Bakgrund: Sjuksköterskor på akutmottagning arbetar ofta i en oförutsägbar och stressig miljö där omprioriteringar behöver göras hela tiden. Att arbeta under dessa förutsättningar kan medföra en risk att uppleva samvetsstress. Forskning inom detta område har gjorts i flera kontexter men väldigt lite forskning är gjord hur den yttrar sig på en akutmottagning. Syfte: Syftet med denna studie var att beskriva sjuksköterskans upplevelse av samvetsstress på akutmottagningen. Metod: En kvalitativ semistrukturerad intervjustudie genomfördes med tio sjuksköterskor från två akutmottagningar med olika storlek. Resultat: Utifrån resultatet framkom sex kategorier och ett tema. Kategorierna var följande: Att medverka till vårdlidande; Bristande kollegialitet som grund för samvetsstress; Organisatoriska brister som grund för samvetsstress; Hantering av upplevd samvetsstress; Konsekvenser av samvetsstress och Lindring av samvetsstress. Temat mynnade ut i Samvetsstress- en börda att förhålla sig till. Slutsats: Tillräckliga resurser och organisatoriskt stöd är viktiga medel för att lindra samvetsstress hos sjuksköterskan. Genom att sjuksköterskan arbetar med sin etiska kompetens och nyanserar kraven på sig själv kan upplevelsen av samvetsstress lindras. / Introduction: Nurses in the emergency room are often working in an unpredictable and stressful environment where constant re-prioritizing is made. Working under these conditions could cause stress of conscience. Research in this field has been made in different contexts but there is little research made in the emergency room. Aim: The aim with this study is to describe the nurse´s experience of stress of conscience in the emergency room. Method: A qualitative semi structured interview study was carried out with ten nurses from two emergency rooms of different size. Result: Six categories and one theme emerged from the result. The categories where the following:  To contribute to care suffering; Lack of collegiality as a cause of stress of conscience; Organizational shortcomings as a reason for stress of conscience; Managing stress of conscience; Consequences for the nurse and Alleviation of stress of conscience. The theme was Stress of conscience - a burden to relate to. Conclusion: Sufficient resources and organizational support are important means to alleviate stress of conscience. If the nurse improves ethical competences and nuances the existing demands, the experience of stress of conscience can decline.

The thesis comprises four papers. The overall aim was to illuminate meanings of becoming and being burnt out respectively not becoming or being burnt out. The papers deal with two groups of healthcare personnel, one group on sick leave due to medically assessed burnout (n=20) and one group who showed no indications of burnout (n=20) from the same workplaces at psychiatric (n=7) and elderly (n=7) care units. A further aim was to describe personality traits and to elucidate perceptions of conscience (PCQ), stress of conscience (SCQ), moral sensitivity (MSQ-R), social support (SocIS) and resilience (RS) among the people in these two groups. Papers I and II are based on the text of narrative interviews interpreted using a phenomenological-hermeneutic method. Papers III and IV are based on data, pertaining to the same participants as in Papers I and II, derived from the following questionnaires; Cattell’s Sixteen Personality Factors Questionnaire (16PF) (III), ‘Perception of Conscience’ (PCQ), ‘Stress of Conscience’ (SCQ), ‘Moral Sensitivity Revised’ (MSQ-R), ‘Social Interactions Scale’ (SocIS) and ‘Resilience Scale’ (RS) (IV). Conventional statistical methods and Partial Least Square Regression (PLSR) were used to analyse the data (III, IV). In Paper I the aim was to illuminate meanings of becoming and being burnt out as narrated by healthcare personnel. The results show that meanings of becoming and being burnt out is to be torn between what one wants to manage and what one can actually manage. It is as if one’s ideals become more like demands for, regardless of the circumstances, one must be and show that one is capable and independent. It also means being dissatisfied with oneself for not living up to one’s own ideals as well as being disappointed in other people for not providing the confirmation one strives for. Feelings that one is a victim of circumstances emerge. Becoming and being burnt out leads to a futile struggle to live up to one’s ideals and when failing to unite one’s ideal picture with one’s reality one finally reaches an overwhelming feebleness. In Paper II the aim was to illuminate meanings of not becoming or being burnt out at workplaces where others developed burnout, as narrated by healthcare personnel. The results show that meanings of not becoming or being burnt out are to be rooted in an outlook on life which perceives its many-sidedness of prosperity, adversity, strength and weakness in oneself and others. An openness towards the circumstances of life emerges. Being able to judge the possibilities of influencing things, as well as being able to let go of injustice and look after oneself with a clear conscience are revealed as meanings of not becoming and being burnt out. In Paper III the aim was to describe personality traits among burnt out and non-burnt out healthcare personnel from the same workplaces. The results show, that the people in the burnt out group had lower scores regarding emotional stability and higher scores regarding anxiety than the people in the non-burnt out group but the results also showed a wide variation of personality traits within the groups. The most important indicators for belonging to the burnt out group were openness to changes and anxiety, and for belonging to the non-burnt out group, emotional stability, liveliness, privateness and tension. In Paper IV the aims were to elucidate perceptions of conscience, stress of conscience, moral sensitivity, social support and resilience among burnt out and non-burnt out healthcare personnel from the same workplaces. The results show that higher levels of stress of conscience and moral sensitivity, a perception of conscience as a burden, having to deaden one’s conscience in order to keep working in healthcare and perceiving a lack of support from those around them characterize the burnt out group. Those in the non-burnt out group are characterised by lower levels of stress of conscience, an out-look on life with a forbearing attitude, a perception of conscience as an asset, an ability to deal with one’s conscience in a constructive way and a perception of receiving support from those around them. The comprehensive understanding from the four papers (I-IV) is discussed in light of a theoretical framework derived from Emmy van Deurzens thoughts about the four life worlds: the natural world (the physical world), the public world (the social world), the private world (the psychological world) and the ideal world (the spiritual world). The result can be summarized in terms of the human condition in life and demonstrates the essential importance of reconciling the vita activa (the active life of labor, work and action), the vita contemplativa (thinking, willing and judging) and not least the vita regenerativa (rest and recovery) in order to avoid being burned out. / Samvetsstress i vården

The overall aim of this thesis is twofold: first, to develop and validate questionnaires that could be used for investigating relationships between perceptions of conscience, moral sensitivity and burnout and second, to describe patterns of self-comfort used to ease stress and illuminate meanings of living with a troubled conscience. The thesis comprises five studies and is based on both quantitative and qualitative data. In study I, a questionnaire was constructed to assess perceptions of conscience; the Perceptions of Conscience Questionnaire (PCQ). This 15 item-questionnaire was distributed to 444 care providers. Statistical analyses of responses showed sufficient distribution and a stable six factor solution congruent with reviewed literature. The six factors were labelled: ‘the voice of authority’, ‘warning signal’, ‘demanding sensitivity’, ‘asset’, ‘burden’ and ‘depending on culture’. The findings suggest that the PCQ is a valid questionnaire. The aim of study II was further development of an existing questionnaire assessing care providers’ moral sensitivity, enabling its use in various care contexts. The revised nine-item questionnaire, the Moral Sensitivity Questionnaire Revised version (MSQ-R), was distributed to 278 care providers with various professional backgrounds. Statistical analyses of responses showed sufficient distribution and a three-factor solution congruent with reviewed literature. The three factors were labelled: ‘sense of moral burden’, ‘sense of moral strength,’ and ‘sense of moral responsibility.’ The findings suggest that MSQ-R is valid for use in various healthcare contexts. In study III, the PCQ, the MSQ-R and the Maslach Burnout Inventory (MBI) were distributed to a population of psychiatric care providers (n=101) to investigate relationships between perceptions of conscience and moral sensitivity and levels of burnout. The hierarchical cluster analysis shows two clusters with Pearson’s r >.50. Cluster A comprising items such as: being sensitive, interpreting and following the voice of conscience that warns us against hurting other or ourselves and developing as human beings was labelled ‘experiencing a sense of moral integrity’. Cluster B comprising items such as: feeling inadequate, doing more than one has strengths for, feeling always responsible, having difficulties to deal with wearing feelings, perceiving that conscience gives wrong signals and express social values, having to deaden one’ conscience, were all related to scores of the MBI subscales emotional exhaustion (EE) and depersonalisation (DP). Cluster B was labelled ‘experiencing a burdening accountability’. The results show that levels of ‘experiencing a burdening accountability’ are closely related to levels of being at risk of burnout. The aim of study IV was to describe patterns of self-comforting measures used to ease stress. The written accounts of 168 care providers and healthcare students were analysed by means of qualitative content analysis. The findings disclose two dimensions: an ability to use early learned measures to take care of oneself (ingression) and an ability to feel intimately related to life, other human beings and universe or God (transcendence). The findings provide valuable knowledge about self-comfort as a coping strategy. The aim of study V was to illuminate meanings of living with a troubled conscience. Ten psychiatric care providers, respondents of study III with various perceptions of conscience were interviewed. The interviews were interpreted using a phenomenological - hermeneutical method. The findings show that one meaning of living with a troubled conscience is being confronted with inadequacy and struggling to view oneself as ‘good enough.’ The comprehensive understanding indicates that inadequacy, both one’s own and that of organization one represents, infuse feelings of shame rather than feelings of guilt. Shame concerns one’s identity and need of reconciliation. Conclusions: The results reveal two ways of encountering a troubled conscience. One is being unable to interpret the ethical demand from a troubled conscience. This is indicated by connections between levels of moral burden and levels of burnout. The other way is being able to interpret the ethical demand and using one’s troubled conscience to develop practical wisdom. This means facing shame of feeling inadequate, reconciling images of the ideal self and self-contempt, and becoming realistic about what one can do. In this process comfort seems to be a mediator of reconciliation.

The overall aim of this thesis is to describe perception of conscience, stress of conscience (stress related to troubled conscience) and burnout, to explore their relationships and to illuminate meanings of the lived experience of troubled conscience in one’s work among registered nurses (RNs) and nurse assistants (NAs) in municipal residential care for the elderly. The thesis comprises four studies; studies I-III are based on questionnaire data from 50 RNs and 96 NAs and study IV is based on interview data from 6 RNs and 6 NAs selected from the participants in the questionnaire study. Questionnaire data was analysed with multivariate statistics (I-III). Narrative interviews were interpreted with a phenomenological hermeneutic method (IV). Study I showed two relationships explaining a noteworthy amount of the shared variance by themselves (25.6% and 17.8%). One relationship was shown between having to deaden one’s conscience in order to keep working in healthcare and stress of conscience related to external demands which was interpreted as having to deaden one’s conscience in order to be able to collaborate with co-workers. The other relationship was shown between having to deaden one’s conscience in order to keep working in healthcare and stress of conscience related to internal demands which was interpreted as having to deaden one’s conscience in order to be able to feel like a good healthcare professional. Study II showed a relationship between stress of conscience and burnout (43.6% explained variance) indicating that experiences of shortcomings and of being exposed to contradictory demands are strongly related to burnout. The relationship between perceptions of conscience and burnout (33.9% explained variance) indicated that having to deaden one’s conscience in order to keep working in healthcare is strongly related to burnout. Study III showed that both RNs and NAs perceived conscience mainly as an asset and a guide and not as a burden in their work. Lack of time and high demands of work influencing home life were the situations related to the highest stress of conscience for both RNs and NAs. The predictive pattern for RNs was interpreted as RNs showing sensitivity to expectations and demands and NAs using their conscience as a guide in their work. Study IV showed that meanings of the RNs’ lived experience of troubled conscience in their work are of being trapped in feelings of powerlessness and a sense of being inadequate. They feel they are failing to live up to expectations from residents and their families, colleagues and themselves because of feelings of powerlessness, cowardice and incompetence. Meanings of NAs’ lived experience of troubled conscience in their work are a sense of being hindered in providing the level of care they would like to provide because of pre-determined conditions and by feelings of being inadequate. They are betraying the residents and themselves by accepting perceived inadequate working conditions and through their own perceived sense of cowardice and negligence. The conclusion of these studies is that stress of conscience is related to burnout among RNs and NAs in municipal residential care for the elderly. Experiences of inadequacy, powerlessness and feelings of being hindered are shown in situations where they have troubled conscience. When the norms of others and/or the pre-determined conditions do not correspond to their own values and norms it may result in the feeling that they cannot perceive themselves as good healthcare professionals.

The overall aim of this thesis is twofold: first, to develop and validate questionnaires that could be used for investigating relationships between perceptions of conscience, moral sensitivity and burnout and second, to describe patterns of self-comfort used to ease stress and illuminate meanings of living with a troubled conscience. The thesis comprises five studies and is based on both quantitative and qualitative data. In study I, a questionnaire was constructed to assess perceptions of conscience; the Perceptions of Conscience Questionnaire (PCQ). This 15 item-questionnaire was distributed to 444 care providers. Statistical analyses of responses showed sufficient distribution and a stable six factor solution congruent with reviewed literature. The six factors were labelled: ‘the voice of authority’, ‘warning signal’, ‘demanding sensitivity’, ‘asset’, ‘burden’ and ‘depending on culture’. The findings suggest that the PCQ is a valid questionnaire. The aim of study II was further development of an existing questionnaire assessing care providers’ moral sensitivity, enabling its use in various care contexts. The revised nine-item questionnaire, the Moral Sensitivity Questionnaire Revised version (MSQ-R), was distributed to 278 care providers with various professional backgrounds. Statistical analyses of responses showed sufficient distribution and a three-factor solution congruent with reviewed literature. The three factors were labelled: ‘sense of moral burden’, ‘sense of moral strength,’ and ‘sense of moral responsibility.’ The findings suggest that MSQ-R is valid for use in various healthcare contexts. In study III, the PCQ, the MSQ-R and the Maslach Burnout Inventory (MBI) were distributed to a population of psychiatric care providers (n=101) to investigate relationships between perceptions of conscience and moral sensitivity and levels of burnout. The hierarchical cluster analysis shows two clusters with Pearson’s r >.50. Cluster A comprising items such as: being sensitive, interpreting and following the voice of conscience that warns us against hurting other or ourselves and developing as human beings was labelled ‘experiencing a sense of moral integrity’. Cluster B comprising items such as: feeling inadequate, doing more than one has strengths for, feeling always responsible, having difficulties to deal with wearing feelings, perceiving that conscience gives wrong signals and express social values, having to deaden one’ conscience, were all related to scores of the MBI subscales emotional exhaustion (EE) and depersonalisation (DP). Cluster B was labelled ‘experiencing a burdening accountability’. The results show that levels of ‘experiencing a burdening accountability’ are closely related to levels of being at risk of burnout. The aim of study IV was to describe patterns of self-comforting measures used to ease stress. The written accounts of 168 care providers and healthcare students were analysed by means of qualitative content analysis. The findings disclose two dimensions: an ability to use early learned measures to take care of oneself (ingression) and an ability to feel intimately related to life, other human beings and universe or God (transcendence). The findings provide valuable knowledge about self-comfort as a coping strategy. The aim of study V was to illuminate meanings of living with a troubled conscience. Ten psychiatric care providers, respondents of study III with various perceptions of conscience were interviewed. The interviews were interpreted using a phenomenological - hermeneutical method. The findings show that one meaning of living with a troubled conscience is being confronted with inadequacy and struggling to view oneself as ‘good enough.’ The comprehensive understanding indicates that inadequacy, both one’s own and that of organization one represents, infuse feelings of shame rather than feelings of guilt. Shame concerns one’s identity and need of reconciliation. Conclusions: The results reveal two ways of encountering a troubled conscience. One is being unable to interpret the ethical demand from a troubled conscience. This is indicated by connections between levels of moral burden and levels of burnout. The other way is being able to interpret the ethical demand and using one’s troubled conscience to develop practical wisdom. This means facing shame of feeling inadequate, reconciling images of the ideal self and self-contempt, and becoming realistic about what one can do. In this process comfort seems to be a mediator of reconciliation.

Bakgrund: Sjuksköterskans arbete präglas av såväl lagar och förodningar men också av värdegrunder och etiska koder vilket medför ett stort moraliskt ansvar. Samvete beskrivs som en grundläggande förmåga att skilja mellan rätt och fel, och att vara i konflikt med samvetet kan innebära att förlora sin identitet och värdighet. Äldre människor på särskilt boende eller som har hemtjänst anser inte att de får tillräckligt bra tillgång till vård, samtidigt som vårdarbete med äldre präglas av underbemanning och låg moral. Syfte: Belysa sjuksköterskors upplevelser av samvetsstress i vårdandet av äldre. Metod: I litteraturöversikten har 15 artiklar analyserats. Utifrån dessa har tre kategorier framkommit vilka är utlösande faktorer och orsaker till samvetsstress, sjuksköterskors upplevelser av samvetssress framkallar samt sjuksköterskors sätt att hantera samvetsstress. Resultat: I studien framträdde flertalet faktorer som orsakar samvetsstress bland sjuksköterskor, däribland onödigt patientlidande och yttre krav. Samvetsstress väckte känslor så som otillräcklighet, maktlöshet och dåligt samvete. För att hantera dessa känslor användes så kallat coping-strategier i form av exempelvis byte av arbetsplats, undvikande av patientkontakt och ifrågasättande av egen kunskap. Diskussion: Situationen på arbetsplatsen i form av konflikter och dåligt ledarskap i kombination med idealbilden av sig själv som vårdare visar ett tydligt samband mellan samvetsstress och även utbrändhet. Ökad förståelse kring ledarskap, konflikthantering samt att försonas med sin egen och andras otillräcklighet kan förebygga samvetsstress. / Background: The nurse profession is characterized by law and constitutions, but also by ethical codes and values, which brings a big moral responsibility. Conscience is described as a basic ability of knowing what is right and what is wrong, and being in conflict with one’s conscience can lead to loss of own identity and dignity. Older people in nursing homes or home-care service consider themselves to have bad access to healthcare. At the same time working in care for older people is characterized by under-staffing and low morals. Aim: Describe nurses’ experiences of stress of conscience in their work with older people. Methods: Analysis of 15 scientific articles. Out of the analysis, three categories emerged; factors and causes of stress of conscience, nurses perceptions of stress of conscience and nurses way of handling stress of conscience. Results: In this study a number of factors that causes stressed conscience among nurses, such as unnecessary patient suffering and outer demands were prominent. Stress of conscience caused feelings of inadequacy, powerlessness and bad conscience. To handle these feelings so called coping-strategies were used, for example change of workplace, avoiding patient contact and questioning one’s own knowledge. Discussions: Nurses’ working conditions, for example conflicts and bad leadership combined with the ideal of oneself as being a caring person shows a clear association with stress of conscience and even sometimes even burnout. An increased understanding of democratic leadership, handling conflicts and reconciling with oneself and others inadequacy can prevent stress of conscience.