Moral distress is a complex and challenging problem that may cause negative biopsycohosical and professional outcomes for critical care nurses. The purpose of this work was to explore the relationship between the ethical climate of the work environment and moral distress as experienced by critical care nurses; and to explore relationships among mediators of stress (nurse characteristics e.g. education (BSN, nonBSN), years certified as a critical care nurse, and tolerance of ambiguity) and their relationship with perceived stress, moral distress, health status and salivary alpha amylase. A descriptive correlational cross-sectional design was used for this pilot study of 100 critical care nurses working in adult intensive care units in one large academic medical center. Data were analyzed using descriptive statistics to characterize the sample and the model variables. Regression analysis using a stepwise regression model building technique was used to determine predictors of the study outcomes (moral distress, health status, and salivary alpha amylase). The findings demonstrate that the ethical characteristics of the work environment and perceived stress were predictive of moral distress, psychological/emotional outcomes and stress symptoms. Other variables thought to mediate these relationships were not significant. Future research is needed to find ways to prevent moral distress from occurring and to support nurses dealing with moral distress.

Changes in health care delivery practices are impacting the provision of care in all venues. Occupational therapists working in hospital settings strive to meet professional mandates for occupation-based practice within a medical-model system. Ethical practice is another aspect of service provision vulnerable to contextual influences. The aims of the two studies reported here were to explore occupational therapists’ experiences with occupation-based practice, and with ethical issues, in hospital settings. Grounded theory methods were employed for both studies. Data were collected via individual, semi-structured interviews with 22 participants for the first study. For the second study, nine participants participated in individual, semi-structured interviews, journaling, and follow up interviews. Data analysis resulted in four emergent themes for each study. The main themes of the first study were Occupation-based practice expresses professional identity; Occupation-based practice is more effective; Occupation-based practice can be challenging in the clinic; and, Occupation-based practice takes creativity to adapt. The four themes of the second study were Anything less would be unethical: Key issues; I trust my gut: Affective dimension of ethical practice; Ethical practice is expected but challenging; and, It takes a village. Occupational therapists negotiate challenges inherent in contemporary hospital-based practice to provide occupation-based services and to practice ethically. Occupation-based practice is perceived to be more effective than biomedical approaches to intervention. Therapists must employ creative strategies to overcome challenges presented by medical-model service delivery contexts in order to provide occupation-based interventions. In comparison to other health care professionals working in adult rehabilitation practice, occupational therapists experience both common and unique ethical issues. A discovery of this study was that occupational therapists also experience ethical tensions related to team members’ and families’ sometimes subtle, and less frequently explicit, requests to falsify recommendations in documentation. Experiences with ethical issues include an inherent affective component in the form of moral distress and a strong sense of caring. The impact of systemic/organizational and relational forces is a reality that contemporary occupational therapists must negotiate in order to provide occupation-based and ethical practice.

I den här studien intervjuas 13 diakoner i Svenska kyrkan om profetisk diakoni och vadde behöver för att utföra den. Syftet med studien är att undersöka diakoners syn påprofetisk diakoni och dess dilemman, kostnader och utmaningar. Slutsatsen är att diakonerna är mycket positivt inställda till profetisk diakoni, men de harsällan tid att ägna sig åt den – kyrkans struktur och ledarskap komplicerar arbetet. Dessutom upplever diakonerna att deras vigningslöften om att arbeta profetiskt kan varamycket tunga att bära och svåra att leva efter, vilket kan utlösa moralisk stress. Diakonerna vill att diakonrollen uppgraderas och ges större frihet, samt att kyrkansledare gå före och visar vägen. / <p>En artikelversion av uppsatsen publicerades i Svensk Kyrkotidning 9/2014, sid 271-273.</p>

Background: Swaziland, a country in Sub-Saharan Africa, with an HIV prevalence of 26 % amongst 15-49 year olds. The nurses work conditions are heavily affected by the high prevalence of HIV/AIDS and of the increasing workload. Moral distress can have implications on the nurse’s social, physical, emotional and psychological wellbeing and can also serve as a wake-up call in morally questionable situations. Aim: To describe moral distress among nurses working with people living with HIV/AIDS in Swaziland. Method: A qualitative semi-structured interview study was carried out at two health clinics in Swaziland. Five nurses who in their daily work interact with patients living with HIV/AIDS were interviewed. Data was analysed using content analysis with an inductive approach as presented by Elo and Kyngäs. Results: The results were divided into two main themes of contributing and protecting factors. Contributing factors were: strain of heavy workload and shortages, powerless over ones work situation, guilt over not doing enough, expectations on being the perfect nurse and work not being recognised. Protecting factors were: providing beneficial care brings meaning and having a supportive and appreciative work environment. Discussions: The results of the study are reviewed in the light of the lifeworld perspective theory. Nurses’ sense of identity is discussed as well as experiences of high expectations, powerlessness and protecting factors such as meaningfulness and peer support. / Bakgrund: Swaziland är ett land söder om Sahara som har en HIV-prevalens på 26 % bland 15-49 åringar. Sjuksköterskors arbetsvillkor har påverkats markant av den höga HIV/AIDS-prevalensen och den höga arbetsbelastningen. Moralisk stress kan påverka sjuksköterskans sociala, fysiska, emotionella och psykiska välbefinnande och kan fungera som en väckarklocka i moraliskt svåra situationer. Syfte: Att beskriva moralisk stress bland sjuksköterskor som arbetar med personer som lever med HIV/AIDS i Swaziland. Metod: En kvalitativ semi-strukturerad intervjustudie genomfördes på två hälsokliniker i Swaziland. Fem sjuksköterskor intervjuades som i sitt dagliga arbete kommer i kontakt med patienter som lever med HIV/AIDS. Innehållsanalys med induktiv ansats enligt Elo och Kyngäs användes för att analysera data. Resultat: Resultatet delades upp i bidragande och skyddande faktorer. Bidragande faktorer var: påfrestning av tung arbetsförda och bristande resurser, maktlöshet över ens arbetssituation, skuld över att inte göra tillräckligt, förväntningar att vara den perfekta sjuksköterskan och att inte uppskattas för sitt arbete. Skyddande faktorer var: att ge gynnsam vård skänker mening samt att ha ett arbetsklimat som stöttar och uppmuntrar. Diskussion: Studiens resultat diskuteras utifrån ett livsvärldsperspektiv. Sjuksköterskornas upplevelse av identitet, höga förväntningar, maktlöshet samt skyddande faktorer såsom meningsskapande och stöd från kollegor diskuteras.

On May 31, 2008, one of Canada’s oldest needle exchange programs was forced to close its doors. Street Outreach Services (SOS), run by AIDS Vancouver Island, was evicted from its fixed site location in downtown Victoria, BC, due to years of inadequate funding and resources, and pressure from community members who blamed SOS for “public disorder” on the city streets. Without a new location from which to house the program, SOS has since operated as a mobile service. This case study documents the context surrounding the closure of SOS and the perspectives of outreach staff regarding the transition from fixed site to mobile services-only. Specifically, this study addresses the question: How have service delivery changes and restrictions impacted SOS outreach work? In addition to participant-observation, media and report analysis, primary data are derived from six semi-structured interviews with SOS outreach workers and a thematic analysis highlights common experiences of loss, isolation and changes in relationships with clients. A discussion of strategies for collective responses to ethical distress includes social justice perspectives. / Graduate

Hospitals today focus on creating a culture of patient safety and reducing error. Registered nurses are mandated by the American Nurses Association's Code of Ethics to advocate for the patient at all times and to act accountably to ensure patient safety. There is a paucity of literature relating to how nurses' values and ethical ideology may affect their decision to act accountably. This study tested two hypotheses. Hypothesis 1 predicted that registered nurses who demonstrated a low relativistic ethical ideology would score higher on a measure of professional values than would registered nurses who demonstrate a high relativistic ethical ideology. Hypothesis 2 predicted an order of ethical ideology (absolutists then exceptionists, subjectivists and situationists) in scores on a measure of accountability. A descriptive non experimental design was used. Registered nurses (n=215) employed on the west coast of Florida completed a demographic form, Ethical Position Questionnaire (EPQ), Nurses Professional Values Scale Revised (NPVSR) and an investigator developed accountability instrument. A median split on the scores of the relativism and idealism scales on the EPQ formed the four groups of ethical ideology; absolutists, exceptionists, subjectivists and situationists. The accountability instrument consisted of 2 hypothetical clinical vignettes involving a late antibiotic administration. Using a Likert type scale, the participants answered three questions regarding how likely they would be to record the actual time of medication administration, call the physician and complete an incident report. Hypothesis I was not supported. Idealism (p=.001) not relativism had a significant effect on professional values. Hypothesis II was not supported. Absolutists scored highest on measures of accountability followed by exceptionists, situationists and subjectivists. When controlling for age, idealism not relativism had a significant effect on completing an incident report (p = .03). This is the first study to examine the effect of ethical ideology on professional values and a registered nurse's intention to act accountably. Previous studies described values held but did not link the descriptions to intentions to act. The information may be useful to hospitals as they build a culture of patient safety and develop a workforce that is accountable for its actions and decisions.

PURPOSE: The purpose of this qualitative descriptive study was to describe critical care nurses’ experiences of moral challenges, moral distress, and moral resilience during the COVID-19 pandemic. The specific aims of this study were to: 1. Describe the moral challenges experienced by ICU nurses. 2. Describe moral resilience in terms of integrity, buoyancy, moral efficacy, self-regulation, and self-stewardship among ICU nurses (from Rushton’s framework). 3. Explore the relationship between moral distress and moral resilience to advance the concept of moral resilience in the face of the COVID-19 pandemic. FRAMEWORK: This study was undergirded by an adaptation of Rushton’s conceptual framework of moral concepts. DESIGN: A qualitative descriptive design was used. Participants were recruited between January to May 2021, and a semi-structured interview guide was utilized to interview participants. RESULTS: 17 participants were interviewed for the study. Participants described the four themes of moral challenges: death and dying, pain and suffering, being alone, and being helpless and not in control. Moral resilience was described as: integrity, buoyancy, moral efficacy, self-regulation, self-stewardship, and self-perception. The relationship between moral distress and moral resilience was described as iterative and fluid. CONCLUSION: The findings of the study provided a new domain of moral resilience called self-perception and a revised adaptation of the conceptual framework for moral resilience.

Bakgrund: Sjuksköterskor förhåller sig till etiska och moraliska värderingar för att kunna ge en etiskt försvarbar vård till sina patienter. Grunden i det etiska vårdandet är att sjuksköterskor använder sina empatiska och sympatiska förmågor. Den etiska förmågan kan påverkas negativt av stress. Stress är ett begrepp med många olika innebörder, en typ av stress som sjuksköterskor utsätts för är den etiska stressen. Den är ofta svårbegriplig och svårhanterbar och uppstår när sjuksköterskor måste göra avkall på sina etiska värderingar. Etisk stress är emotionellt utmanande och kan få många konsekvenser i vårdandet av människor.  Syfte: Att belysa sjuksköterskors upplevelser av etisk stress Metod: En litteraturöversikt av tio vetenskapliga artiklar med kvalitativ design. Artiklarna analyserades enligt Fribergs analysmetod där författarna sökte efter delar i artiklarnas resultat med betydelse för litteraturöversiktens syfte. Vilket gav ett resultat i form av teman och subteman. Resultat: Analysen resulterade i fyra huvudteman: Upplevda känslor vid etisk stress, Situationer där känslor av etisk stress uppstår, Möten som gör sjuksköterskan sårbar och Hantering av känslor vid etisk stress. Till det sistnämnda huvudtemat hör två subteman. Dialogens betydelse och Personliga förutsättningar och erfarenheter. Diskussion: I resultatet diskuteras upplevelsen av etisk stress utifrån Travelbees teori om sjuksköterskan och andra relevanta studier. Vikten av gemensamma etiska riktlinjer mellan sjuksköterskor och läkare diskuteras och behovet av etisk vägledning och stöd vid svåra möten i vården. Olika etiska problem diskuteras utifrån sjuksköterskors roll i vården. Betydelsen av kommunikation och dialog för bearbetning av etiskt stress hos sjuksköterskor diskuteras. / Background: Nurses act on ethical and moral values to be able to give their patient ethical care. The foundation of the ethical care that nurses provide is based on their empathic and sympathetic abilities. The ethical ability can negatively be affected by stress. The definition of stress is a wide concept with different meanings. One specific type of stress that nurses encounters is the moral distress which is hard to explain and difficult to handle. The moral distress emerges when nurses are unable to act according to their moral judgment. Moral distress is emotional challenging and may affect patient care. Aim: To illustrate nurses’ experiences of moral distress. Method: The study is a literature review containing ten articles of qualitative design. The articles were analyzed according to Friberg’s method. In which results relevant to the aim were categorized and subsequently referred to themes and sub-themes. Results: The analysis resulted in four major themes: Experienced emotions of moral distress, Situations where feelings of moral distress is experienced, Encounters that’s makes nurses vulnerable and Handle the emotions of moral distress. The latter major theme included two sub-themes: The importance of dialog and Personal abilities and experiences. Discussion: The results of the literature review have been discussed in relation to Travelbees nursing theory and perception of the nurse and other relevant studies. The importance of mutual ethical guide lines between nurses and doctors is discussed and the need of ethical guidance and support in difficult care situations. The meaning of dialog and communication to make moral distress manageable for nurses is discussed.

Att söva barn kan vara en utmaning för anestesisjuksköterskan då barn ofta är oroliga inför en operation. Oron kan orsaka lidande hos barnet och väcka ett medlidande hos anestesisjuksköterskan vilket kan orsaka en värdekonflikt mellan önskan att respektera barnets ovilja att sövas och viljan att hjälpa barnet. Syftet med studien var att undersöka anestesisjuksköterskors upplevelser av att söva oroliga barn. Metoden var semistrukturerade intervjuer som sedan analyserades med kvalitativ innehållsanalys med induktiv ansats. Detta ledde fram till fyra kategorier och tio subkategorier. Kategorierna var Känsla av att ta hand om hela familjen, Betydelsen av att skapa kontakt med barnet, Känsla av att förutsättningar påverkar sövningen och Den etiska utmaningen i att söva oroliga barn. Resultatet visar att det upplevs viktigt att ta hand om hela familjen och inte bara barnet. Anestesisjuksköterskan behöver lugna oroliga föräldrar och etablera en god kontakt med barnet, anpassad efter barnets individuella behov. Goda förutsättningar, såsom gott teamarbete och erfarenhet, är viktiga aspekter som underlättar sövningen av oroliga barn. Anestesisjuksköterskan kan uppleva misslyckanden om det inte går att lugna barnet och att behöva tvångssöva ett barn kan orsaka skuldkänslor och stress. Om operationen är nödvändig och barnet måste sövas mot sin vilja upplevs det viktigt att ha gjort sitt bästa och med barnets bästa i fokus. / Inducing general anesthesia in pediatric patients can be challenging as pediatric patients often experience anxiety before undergoing surgery. Anxiety can be distressing for the child that in turn might affect the nurse anesthetist causing stressful emotions. It might also cause a conflict of values between the nurse anesthetist’s desire to respect the child’s wish to avoid undergoing anesthesia and the desire to care for the child. The objective of the study was to investigate nurse anesthesiologists’ experiences of inducing general anesthesia in anxious pediatric patients. The method was semi-structured interviews with qualitative content analysis and inductive approach. Four categories and ten subcategories emerged. The categories were: The notion of providing care for the whole family, The importance of establishing a nurse-patient relation with the child, The notion that working under proper conditions affects the induction of anesthesia and Ethical challenges in inducing a state of general anesthesia in anxious children. Results show that the nurse anesthetists feel it important to provide care for the whole family and not just to the child. The nurse anesthetist needs to calm anxious parents while establishing a beneficial patient relation, tailored after the needs of the child. Working under favorable conditions facilitates inducing general anesthesia in anxious children. The nurse anesthetists experience feelings of failure when they do not succeed in calming anxious children. Failing to calm the patient can also cause stress and feelings of guilt. In the case of non-elective surgery where a state of general anesthesia must be induced against the will of the child, the nurse anesthetists experience that it is important to do the best of their ability while focusing on what is best for the child.

Bakgrund: Stress är vanligt förekommande hos yrkesverksamma sjuksköterskor och nämns som en grundläggande orsak till psykisk ohälsa och ökat antal sjukskrivningar. Arbetsmiljöverket rapporterar in yrkesrelaterad stress som den vanligaste sjukskrivningsorsaken bland vårdpersonal. Moralisk stress definieras som situationer då vi vet vad som är rätt att göra, men institutionella begränsningar gör det i princip omöjligt att göra det rätta. Syfte: Att beskriva sjuksköterskors upplevelser av moralisk stress. Metod: En deskriptiv litteraturstudie med tematisk dataanalysmetod som utgår från 13 vetenskapliga artiklar som svarar på studiens syfte.  Huvudresultat: Resultatet visade att när det finns brister i behandlingen som patienterna erhåller och kvaliteten på vården sviktar upplever många sjuksköterskor moralisk stress. Det visade även att samarbetssituationer, kommunikationsbrister och kontakter med anhöriga kan vara källor till moralisk stress. Den moraliska stressen utlöstes i de situationer där sjuksköterskor upplever att patienterna blir lidande och då sjuksköterskan upplever att hon inte kan agera på det sätt som är bäst för patienten. Som en konsekvens av den moraliska stressen upplever sjuksköterskorna flera varierande negativa känslor, där frustration är den mest frekventa känslan. Slutsats: Upplevelser av moralisk stress är vanligt förekommande bland kliniskt arbetande sjuksköterskor. Den moraliska stressen uppkommer i situationer där sjuksköterskor inte kan agera på det sätt som sjuksköterskorna anser är rätt. Som en konsekvens av den moraliska stressen upplever sjuksköterskorna flera olika negativa känslor. Genom att få en förståelse för vad moralisk stress är, hur den uppkommer och hur den yttrar sig känslomässigt kan sjuksköterskor lättare hantera sina egna reaktioner då de upplever moralisk stress. / Background: Stress is common among nurses and is mentioned as a fundamental cause of an increased number of sick leaves and mental illness. The Swedish Work Environment Authority reports occupational stress as the most common cause of sick leave among healthcare professionals. Moral distress is defined as situations when we know what is right to do, but when institutional limitations make it impossible to do the right thing. Aim: The aim of this study was to describe nurses' experience of moral distress.  Methods: A descriptive literature study with a thematic data analysis method based on 13 scientific articles that answer the aim. Main results: The result revealed that deficiencies in the treatment that patients receive and the quality of care declines, many nurses experience moral distress. It also revealed that cooperation situations, deficiencies in communication and contacts with relatives can be sources of moral distress. The moral distress is triggered in the situations where nurses feel that the patients are suffering and when the nurse feels that she cannot act in the best way for the patient. As a consequence of the moral distress, the nurses experience several varying negative emotions, where frustration is the most frequent emotions. Conclusion: Experiences of moral distress are common among clinically working nurses. The moral distress arises in situations where nurses can’t act in a way that the nurses think is right. As a consequence of the moral distress, the nurses experience several different negative emotions. By gaining an understanding of what moral distress is, how it arises and how it manifests emotionally, nurses can more easily manage their own reactions when they experience moral distress.