Workplace distress and ethical dilemmas in neuroscience nursing.

The nurses felt they could not do their job properly and felt inadequate because they made heavy demands on themselves. Those with limited experience as nurses felt a great deal of tension when they started, and they regretted not having been given an adequate introduction to their new workplace. The stressful working situation had the result, as the nurses saw it, that they constantly had to change their prioritization of the work.

The demands made on them by relatives of the patients were felt to have increased. Relatives would insist on speaking to the physician immediately and did not accept waiting. These sometimes unrealistic demands and dissatisfaction were hard to handle and resulted in sadness and frustration among the nurses interviewed. Another source of stress was the administrative work, which was viewed as burdensome. In particular, planning for the patients' aftercare resulted in increased administrative work and less time spent with the patients. This time allocation was experienced as negative.

The physical working environment was perceived as lacking patient wards that were spacious enough for both patient care and the needs of visiting families. Also, the mental environment was experienced as stressful. This was mainly the result of the impending reorganization and merger of some departments, including their own. This created a lot of uncertainty and required a great deal of energy. The nurses also expressed dissatisfaction with the salary and the new work schedule. They felt that they could not influence their working situation they could not, for example, influence either the fact that there was a shortage of nursing staff on a certain shift or the frequent reorganizations and demands for spending cuts. There were routines, political decisions, and economic factors that they felt hindered them from working the way they wanted.

Lack of communication and cooperation with other healthcare team members. The nurses felt that they were not appreciated by the physicians and not respected as professionals. Their knowledge about the patients was not seen as valuable, and their suggestions were not welcomed by all of the physicians.

The nurses did not always have the information they needed from the physicians and had to ask for it. In addition, the lack of cooperation and communication was thought to result from a hierarchical structure in which physicians had more power and influence than the nurses. According to the nurses, the cooperation and communication with other members of the nursing staff did not always function satisfactorily. There was a lack of understanding of the nurses' responsibilities on the part of the assistant nurses, especially when the workload was heavy. The assistant nurses wanted the nurses to help them in the essential care, but the nurses often had medical tasks to perform, and this could result in conflicts. Conflicts also arose between nurses, for example, when it was perceived that not everyone took enough individual responsibility for her or his work, and between nurses and physicians when the nurses thought that the physicians were not treating the patients or families respectfully.

Disagreeing with colleagues made the nurses sad. In difficult situations the nurses had experienced a lack of support from other members of the nursing staff and from the clinic management. Cooperation and communication with the staff in the public community care about the patients' aftercare was described as dysfunctional and difficult. The nurses did not feel that they could influence decisions, nor did they perceive that their views were seen as useful and important.

Difficulty witnessing the situation of seriously ill patients. When the patients were young and seriously ill, often because of a brain tumor, the nurses felt sad. They felt sympathy for these patients. Sometimes the patients were close in age to the nurses, and then their condition affected the nurses even more; they felt helpless. If these patients had small children, the nurses felt that it was especially unfair that they should be stricken with illness because they had their whole lives before them. It could be hard to stop thinking of the patients after work, and the nurses wondered what the future held for those whose prognosis was uncertain. It was very mentally demanding to take care of these patients.

Ethical Dilemmas

Troublesome decision making on initiation or withdrawal of treatment. Dilemmas often concerned initiating or withdrawing a certain treatment, and it was felt that each decision was unique.

The dilemma was, as the nurses saw it, whether the patient would benefit from the treatment or if the treatment would cause pain or prolong suffering. The nurses believed that treatment should not be initiated or continued just because it was possible. The price the patient had to pay could be too high, and the patient's quality of life had to be considered. The decision-making process was experienced as difficult, and the nurses felt powerless, for example, when withholding fluid from a patient who could not swallow or when explaining to the family that the patient's infusions would be discontinued. One distressing situation involved withdrawing life-sustaining treatment, but the patient continued to live. Distress was also involved in caring for a patient where no decision about continued treatment or withdrawal of treatment had been made. The lack of a decision, or an incomprehensible shift between active treatment and no treatment at all, was emotionally difficult to bear. The decision making was perceived to be influenced by a number of factors, such as the physician responsible and the age of the patient. The diagnosis was also a determining factor when deciding about life-sustaining treatment, because it was felt that patients with certain diagnoses received much more treatment than patients with other diagnoses.

Conflicting views on right treatment and decision. Nurses and physicians sometimes held different opinions concerning the right treatment or decision for the patient. When the physician had decided on further treatment, but the nurse thought that the treatment should be terminated, the nurse was frustrated and angry at having to examine and treat a patient who was dying. However, sometimes the nurses thought that the physicians' decisions to terminate treatment were too rash.

It was very difficult to nurse a patient who was conscious, but the treatment had been terminated. The physicians did not always include the nurses in the decision making, and the lack of cooperation negatively affected patient care. The family and the nurses could have conflicting views on treatment and decisions, and there arose a dilemma concerning whether the decision should be made in accordance with the relatives' views or those of the nurses. It could be difficult to resolve such a dilemma because the nurses lacked time and knowledge and because of the physicians' attitudes.

Difficulties in providing for patients' and families' needs, rights, and desires. The nurses indicated that it was difficult to maintain the patient's integrity. This was the case, given that many of the patients had to share a room, and sometimes they had to be placed in the corridor. At such times it was almost impossible to talk privately to the patient.

Integrity was also threatened when the nurse had to persuade the patient to accept a new living arrangement. The municipality could not always afford a living arrangement that would be the best for the patient, and the aftercare was thus not directed by the patient's need. During the coordinated-care-planning meetings, where care staff and the social welfare case officer discussed the aftercare of the patient, there could be a problem because the patient was not included in the discussion. Thus the patient did not play a part in the decision making regarding his or her own care. There was a dilemma when the patient was in too poor a state of health to participate or was too shy to do so. The nurses had an ambivalent view of family participation. On one hand, nurses wanted families to be more involved in the decision making concerning the care of the patient; on the other hand, the families might have too much influence, and the patient's care would be provided on their terms.

Managing Distress and Ethical Dilemmas

Accepting and adjusting to the situation in an active way. The nurses accepted the decision about the care of the patient made by the physician or social welfare case officer, but they did not always agree with it. They also accepted the fact that people are of different opinions, and therefore they tried to compromise. They could express their opinions even when they knew that it would not change the decision because they felt it was important to make their own opinions clear as a means of accepting the decision.

Some of the nurses accepted that it was difficult to influence the decisions and the way of working, and they decided to adjust to that fact and the norms of the group on the ward. Others adjusted to the situation by trying to take control over it, for example, by using the time in the most effective way. They planned and prioritized their work and sought to share their time fairly among their patients, thus giving equal attention to the quiet patients.

Seeking support from colleagues. It was of great value to have the opportunity to talk to colleagues about ethically difficult situations. These conversations could take place during coffee breaks or when reporting to the next shift, but a more formal meeting could be organized when there was a situation that involved the whole staff. The nurses related that the informal discussions involved the nurses and sometimes the physician, while the discussions planned beforehand included the nurses, the physician, and, when necessary, the medical social worker. Both nurses and physicians could initiate these discussions. The subject of discussion was often decisions about life-sustaining treatment. Sometimes the discussions took place before the physician made his or her decision in order to throw light upon as many aspects of the situation as possible. At other times the decision had already been made, but the nursing staff felt that they did not agree with the decision, and therefore they initiated a discussion with the physician to better understand the reasons for the decision.

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