Workplace distress and ethical dilemmas in neuroscience nursing.

When it came to managing distress and ethical dilemmas, the nurses primarily relied on coping strategies, and planned discussions about it were rare. Seeking support from colleagues was a common strategy, which is in accordance with the results in another Swedish study (Cronqvist et al., 2006). Nurses may turn to each other for support because they feel more comfortable with colleagues they know than people unknown to them--as may be the case if these situations are discussed in a larger group. But it may also reflect nurses' perception that there is a lack of organized support at the workplace (Cronqvist et al., 2006), which some of the nurses expressed in the present study. Kalvemark and colleagues (2004) found that discussions about ethical issues occurred most often during coffee breaks, and it was only when there had been an especially difficult situation that the nurses met for a more formal discussion.

Systematic clinical nursing supervision has been suggested as one way to handle distress. It has been shown to increase nurses' moral sensitivity, but on the other hand, nurses who were under clinical supervision reported higher levels of stress than nurses who were not (Severinsson & Kamaker, 1999). Organized discussions on ethical problems may be in the form of ethics rounds, where hearing others share their perspectives and experiences can help clarify one's own standpoint. The participants listen to one another's opinions, and in that way values at stake for all concerned are identified (Hansson, 2002). There are few studies that discuss the value of ethics rounds, but in one study (Raines, 2000), the nurses ranked them among the least helpful support resources when dealing with ethical issues. However, this is an area that needs further investigation. If, as Chambliss (1996) argued, nurses' distress reflects organizational problems, managing the distress cannot solely be a question of enhancing the communication among members of the healthcare team, increasing the amount of education, or holding ethics seminars--changes at the organizational level are also required.

Because little is known about neuroscience nurses' experiences of workplace distress and ethical dilemmas, a qualitative method was used. This is the method recommended when there is little or no literature describing the population in question (Brink & Wood, 1998). When a qualitative method is used, it is often impossible to generalize the findings to a broader group. Another limitation of this study was that the sample was taken from one hospital. However, the trustworthiness of this study is strengthened by previous research; the main results of this study are in accordance with those in previous studies. Lambert and colleagues (2004) found that nurses working in different countries reported similar workplace stressors, and therefore the findings may be transferable to other neurological departments and healthcare settings similar to the Swedish system.

Summary

The results of this study show that workplace distress is a major problem for neuroscience nurses. Too great a workload and lack of time were factors that the nurses perceived as hindering high and stable nursing quality. This caused frustration among the nurses, and they felt powerless because they found it difficult to influence their working conditions. Ethical dilemmas mainly concerned decision making about the initiation or withdrawal of treatment. The nurses perceived that they were left out of the decision-making process and that this negatively influenced the care of the patient. When trying to manage the distress, the nurses mainly used coping strategies and sought support from colleagues, and the nurses regretted that there was no regular forum to discuss ethically difficult situations. The findings of this study indicate a high level of concordance with the results from previous studies conducted in different countries (Bucknall & Thomas, 1997; Hilden et al., 2004; Kalvemark et al., 2004; Oberle & Hughes, 2001), and therefore the results may be transferable to neuroscience nurses outside of Sweden and Europe. In light of this study's results, future research should investigate whether such a forum may facilitate the management of distress and the communication and cooperation between professions. It would also be of interest to study the relationship between different coping styles and the nurses' physical, mental, and social health. Finally, to further emphasize the ethical dimension in moral distress, future studies should explore which ethical principles nurses feel are at stake in specific situations.

Acknowledgments

The study was supported by grants from the School of Health Sciences, Jonkoping University, Sweden. We are very grateful to research assistant Camilla Johansson (CJ), MScN RN, for assisting with the analysis in the study.

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