Workplace distress and ethical dilemmas in neuroscience nursing.

Abstract: This study concerns Swedish nurses' experiences of workplace stress and the occurrence of ethical dilemmas in a neurological setting. Qualitative interviews were conducted with 21 nurses. The interview results were subjected to qualitative latent content analysis and sorted into 4 content areas: workplace distress, ethical dilemmas, managing distress and ethical dilemmas, and quality of nursing. Common workplace stressors were high workload and lack of influence. These were perceived to have negative consequences for the quality of nursing. Ethical dilemmas mainly concerned decision making on initiation or withdrawal of treatment, which was experienced as a troublesome situation where conflicts could arise. The nurses managed the distress and ethical dilemmas by accepting and adjusting to the situation and seeking support from colleagues. They also endeavored to gain new strength in their private lives.

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Neuroscience nurses, like other nurses, work in healthcare systems that undergo continual change. In Sweden, the changes in the healthcare system during the past 10 years have led to a greater demand for healthcare services, new discoveries in medicine, and greater demands by better-informed patients and families (Forsberg, 2001). All this contributes to ethical dilemmas and workplace stress, which have increased during recent decades and had a greater impact on nurses (McVicar, 2003). In a review by McVicar, six sources of workplace distress for nurses were identified: workload, relationship with other clinical staff, leadership and management issues, emotional demands of caring, shift working, and lack of reward. Nurses working in different areas of practice reported similar stress levels, but they ranked the stressors differently (McVicar). The workplace stressors are the same from one country to another, according to a cross-cultural study of workplace stressors. The highest-ranked stressors in the countries compared in the study were workload and dealing with death and dying (Lambert et al., 2004). Constant changes in the organizations where nurses work and in job designs also added to workplace stress (Clegg, 2001). Closely related to the concept of workplace stress is role stress, which is the result of unfulfilled role expectations. Factors contributing to role stress include lack of control over the work situation; shortage of resources; concern for the quality of nursing; and lack of cooperation among patients, families, and staff members (Chang, Hancock, Johnson, Daly, & Jackson, 2005).

Ethical dilemmas in nursing have been related to lack of resources such as staff and time, conflicts of interest involving professional hierarchies (Kalvemark, Hoglund, Hansson, Westerholm, & Arnetz, 2004), difficulties with regard to preserving patients' integrity (Kalvemark et al.; van der Arend & Remmers-van den Hurk, 1999), and situations where patients are given, or are at risk of being given, unnecessary treatment (Raines, 2000). The research on workplace or role stress and ethical dilemmas has investigated different healthcare settings, but no study has been found that explicitly deals with the stress and dilemmas experienced by nurses working in a neurological setting. Neuroscience nurses care for patients with severe neurological conditions involving a complex mix of sensorimotor, cognitive, and emotional impairments (Banich, 2004; Hickey, 2003). These illnesses have a great impact on patients' lives and the lives of their families. This means that neuroscience nurses must be proficient in handling life-threatening situations, rehabilitation, and long-term palliative care. A limited number of studies examining Swedish nurses' experiences of workplace stress and ethical dilemmas have been carried out (Cronqvist, Lutzen, & Nystrom, 2006; Crongvist, Theorell, Burns, & Lutzen, 2001, 2004; Hertting, Nilsson, Theorell, & Larsson, 2004; Kalvemark et al.; Olofsson, Bengtsson, & Brink, 2003; Sporrong, Hoglund, & Arnetz, 2006), but none of them has dealt with the experiences of nurses working with neurology patients. The aim of this study was therefore to describe Swedish nurses' experiences of workplace stress and the occurrence of ethical dilemmas in a neurological setting.

Methods

Sample and Participants

The participants were drawn from two departments at a university hospital in Sweden. The physician in charge gave permission for the study to be performed. The project leader (the fourth author) informed the nurse manager of each department about the study and the procedure of data collection. All 21 nurses working the day shift received a letter with information about the study. The nurse manager informed them about the study orally and asked whether the nurses would be willing to participate in the study. In the written and oral information that preceded the data collection, it was clearly stated that participation was voluntary and confidentiality was assured. Participation in this study was based on informed consent and conducted in accordance with the Swedish act concerning the ethical review of research involving humans (Swedish Code of Statutes, 2003), the ethical principles for medical research involving human subjects (World Medical Association, 2004), and the ethical rules and guidelines established by the Swedish Council for Research in the Humanities and Social Sciences (2007). Completion of the interview was viewed as consent. Participation or refusal to participate was not linked to the individual nurses' jobs or performance reviews. Of the 21 nurses who were asked to participate, only one did not want to because of a lack of time for an interview. One nurse who mainly worked night shifts but had many years' experience of working day shifts was then invited to participate and was included in the study. Ultimately, 21 nurses participated in the study. Descriptive data on the study group are shown in Table 1.

Interviews

The interviews were performed over a 3-week period. They were carried out as conversations based on an interview guide that included some general questions as well as individualized follow-up questions. The interview guide consisted of the following general questions:

* What upsets you at work?

* When do you feel displeasure at work?

* What situations at work make you sad after a working day?

* Do you experience ethical issues/dilemmas in your work? If yes, can you give an example of a situation where one of these issues/dilemmas appeared?

* If yes on the latter question, how did you try to cope with this situation?

* How do you perceive the quality of nursing on your unit?

* Do you experience a discrepancy between the actual quality of nursing on your unit and the desirable quality?

* If yes on the latter question, how do you try to cope with this discrepancy?

* What in the working environment is an obstacle to resolving ethical issues/dilemmas at your work?

Follow-up questions were asked, their scope and number depending on how precisely and fully the person had answered the general questions. The interviews lasted 45-80 minutes and were audio-recorded. They were transcribed verbatim by an experienced secretary.

Analytical Procedure

The interviews were subjected to qualitative latent content analysis, whereby the underlying meaning of the text was interpreted (Downe-Wamboldt, 1992; Graneheim & Lundman, 2004). The analysis had an inductive approach. At first, the interviews were listened to and read through several times to obtain a sense of the whole. Then each interview was divided into meaning units, for example, sentences or paragraphs that related to the same central meaning (Graneheim & Lundman, 2004). In the next step, the meaning units were condensed so that the essential content was clear. The condensed meaning units were abstracted and labeled with codes, and from these codes, subthemes and preliminary themes were generated. The meaning units, codes, subthemes, and preliminary themes were sorted using the framework of content areas (Graneheim & Lundman), which had been developed on the basis of the interview questions. Thereafter, the interpretation of the underlying meaning or latent content of the codes, subthemes, and preliminary themes led to the formulation of themes within each content area. The analysis was discussed at several meetings with the researchers (the first author and CJ) who did the original analysis. The trustworthiness of the results was further guaranteed by critical scrutiny of the analyses by the two other authors experienced in qualitative research (the third and fourth authors). This resulted in a few refinements of codes, subthemes, and themes.

Findings

All 21 nurses interviewed experienced ethical dilemmas and distress in their job to some extent (Table 2). In keeping with the aim of this study, the results are grouped according to the themes of the four content areas: workplace distress, ethical dilemmas, managing distress and ethical dilemmas, and quality of nursing.

Notwithstanding the focus on distress and ethical dilemmas, a majority of the nurses (16 out of 21) also expressed satisfaction with components of their working situation. They liked their jobs and thought that neurology was an exciting field in which to work, and they could see how the patients' medical treatment benefited from developments in the field. There was a positive spirit of camaraderie that was important with regard to coping with the demanding working situation. The communication among the nurses was good, and they supported each other. The work was seen as meaningful, especially when patients recovered and made progress.

Workplace Distress