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Weekly UpdatesHearing the reasons for the decision helped the nurses to move on and could also result in a reconsideration of their own attitudes. They wished there was a forum, for example, ethics rounds, to discuss difficult situations together.
Striving for new strength in private life. Not taking home thoughts about work and patients was another way to manage distress. This had been difficult when nurses were just starting out, but it had become easier with increased working experience. It was important not to let work influence your private life, but sometimes it was hard to let go. Often, the nurses talked about their work stressors to family or friends. It could be particularly helpful to talk to family members or friends who were nurses themselves because they were likely to have a better understanding of the situation, but sometimes it was a relief to talk to someone not involved in nursing.
Off-duty time provided the nurses an opportunity to renew their strength and keep work in proportion by taking care of themselves. An example offered was going for walks to clarify their thoughts.
Reflective thinking and previous experiences. In stressful situations, when there was a heavy workload, the nurses tried to identify their own limitations. They did their best, and at the same time did not see themselves as irreplaceable, trusting that the nurses working the next shift could carry on with the tasks they had not managed to finish.
The nurses also recognized their own limitations when they directed the patient or family to another member of staff. For example, they consulted the medical social worker when they thought that they were not the best suited to handle particular situations. In difficult situations they used every available means to do their best for the patients, and then they would be satisfied with their own work, even if the situation did not have the outcome they desired. Another strategy used by the nurses was to look upon the situation from another person's point of view to shed new light on it. When the situation involved decision making with regard to life-sustaining treatment, it could be helpful to have a holistic view of the patient to understand the physician's decision and to give full weight to the patient's human dignity. More experience as a neuroscience nurse reduced distress and increased confidence in handling different kinds of situations, and it had also made it easier to prioritize. Working experience also enabled the nurse to reflect on ethically difficult situations from different perspectives.
Quality of Nursing
Satisfaction with nursing quality and the individualized care. The quality of nursing care was judged as being high by a large majority of the nurses. They thought they were able to maintain high quality even though sometimes there were not enough nurses, which ultimately did have negative consequences for them. Factors that contributed to high-quality care were well-qualified nurses with specialized knowledge about neurological diseases, a holistic view of the patient and his or her situation, and teamwork with other groups of healthcare providers.
The nursing staff often received appreciation from families and patients who were satisfied with the care, even though the nurses felt that they had not done much. The satisfaction of families and patients has also been shown in opinion polls, where nurses received good ratings for the care they provided. The care of the patient was individualized as much as possible--each patient, for example, had his or her own training program during rehabilitation. The nurses also took measures to increase the participation of patients in their own care through information and in conjunction with decision making at coordinated care planning meetings. Nurses left the room to allow the patient to take a more active part in the decision making during such a meeting. The high quality of nursing care was also evident in the kind treatment of the families, which was considered an important part of good care. The relatives received individualized information about the patient's condition, and the nurses lent a sensitive ear to the family's desires. When the family participated in decision making with regard to the patient's care, the nurses supported them.
Lack of nurses and time hinders stable and high nursing quality. Although there was a general satisfaction with the nursing quality, there was room for improvement. The quality was thought to be dependent on the workload and the number of nursing staff working. This meant that the quality was thought to be unsatisfactory when the workload was too heavy or there were too few nurses, which could be the case on evening shifts and on weekends. On these occasions, the nurses felt that they could not provide for all patients' needs, and that scarce resources hindered recovery and rehabilitation. Nurses felt that they did not have time to properly talk to the patients and could not always give them the basic care, despite the fact that the patients were experiencing life-threatening or life-changing diagnoses and needed to share their feelings with the nurses. Nor was there time to do something special, for example, go for a walk with the patient. The nurses' time for answering the families' questions was limited and caused them dissatisfaction.
Changing working conditions, such as new work schedules, and the future reorganization of the clinic, were other factors cited by the nurses as causing a decline in the quality of nursing and an interruption to the continuity of care. In conjunction with the reorganization, some of the nurses with specialized knowledge would be transferred to another clinic, and they were concerned that this would negatively affect the quality of nursing care.
Discussion
The aim of this study was to describe Swedish nurses' experiences of workplace stress and the occurrence of ethical dilemmas in a neurological setting. The results are in line with previous findings; ethical dilemmas cause distress among nurses (Kalvemark et al., 2004). Key components found in all content areas were high workload and nurses' difficulties with regard to influencing their working environment and decisions regarding patients' care. The relationships and cooperation with other healthcare team members were described as not quite satisfactory, and the nurses had an ambivalent view of the role of the family. There was a general satisfaction with the quality of nursing care, but a lack of time and nursing staff always threatened this quality. The nurses described different ways of managing the distress and the dilemmas; they mainly accepted and adjusted to the situation and sought support from colleagues.
The main causes of workplace distress were the demanding working situation and workload and a lack of influence. Distress caused by a heavy workload--due to a shortage of staff in relation to the number of patients--is in line with findings in previous studies (Hertting et al. 2004; Olofsson et al., 2003). This had consequences for the quality of nursing care, which was thought to be unsatisfactory when nurses did not have time to meet patients' needs. A lack of time may imply that the nurses have to set priorities that are contradictory to their nursing principles (Cronqvist et al., 2001). Nurses are also in a position where they often lack influence over their working situation and the decisions they have to follow through on (Oberle & Hughes, 2001), which was evident in the present study. One kind of stress nurses may experience is moral distress. Jameton (1984) defined moral distress as occurring when "one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action" (p. 6).
This definition was further developed by Wilkinson (1987), who defined such distress as "the psychological disequilibrium and negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behaviors indicated by that decision" (p. 16). The nurses in this study expressed moral distress in terms of wanting to do the best for their patients but being hindered by a shortage of staff, routines, and economic factors. The nurses' descriptions of fatigue, frustration, and inadequacy are also in line with Wilkinson's report documenting the negative feelings that moral distress produces. The consequences of moral distress are serious, the most extreme such consequence being that nurses leave the nursing profession altogether (Wilkinson). Chambliss (1996) argued that ethical problems and the resulting distress should not be viewed as isolated incidents or as personal issues, but as systematic issues created by the hospital organization. This perspective is applicable to the present study, because the results indicate a high level of concordance among the nurses regarding what was viewed as stressful, and these issues were mainly related to organizational factors.
The most common ethical dilemmas revolved around making decisions about whether to initiate or withdraw treatment. In accordance with previous research (Oberle & Hughes, 2001), the nurses in this study found the decision-making situation difficult, and the main dilemma to be deciding when suffering outweighed the benefits of treatment. The nurses perceived that in some cases the decision was made too late. This indicates that in their opinion a greater number of patients should receive limited treatment, which is in line with previous studies (Bucknall & Thomas, 1997; Hilden, Louhiala, Honkasalo, & Palo, 2004), but they also expressed the opinion that decisions to limit or withdraw treatment could be made too early. At the same time, the nurses perceived that they were left out of the decision-making process. This may imply that they did not have sufficient information about a physician's decision, and this resulted in their holding a different opinion regarding the level of treatment. Several studies (Bucknall & Thomas; Ferrand et al., 2003, Manias, 1998; Rocker et al., 2005) have described nurses' conceptions of being left out of decision making regarding treatment; in the present study the nurses expressed the opinion that this had negative consequences for the care of the patient. The inclusion of nurses in the decision-making process could have several advantages. First, the nurses complement the medical basis for decision making with their knowledge about the patient. If nurses are given the opportunity to discuss decisions with the physician, nurses may find it easier to care for patients even if the they do not agree with the physician's decision. Disagreements regarding aggressiveness of treatment also arose between staff members and family. In this instance, nurses were ambivalent about families' participation. The view of the family as having too much influence is in line with previous results (Hilden et al.; Viney, 1996). However, the ambivalence about the role of the family was not found in previous research.
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