Ethical Issues Hw
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Article_Nurses_experiences_of_ethical_dilemmas.pdf
Nursing Ethics
Volume 27, Issue 1, February 2020, Pages 258-272
© The Author(s) 2019, Article Reuse Guidelines
https://doi.org/10.1177/0969733019832941
Original Manuscripts
Nurses experiences of ethical dilemmas: A review
Anita Haahr 1, Annelise Norlyk, Bente Martinsen2, and Pia Dreyer2,3
Background: Nursing care is rapidly evolving due to the advanced technological and medical development, and also due to an increased focus on standardization and the logic of production, permeating today’s hospital cultures. Nursing is rooted in a holistic approach with an ethical obligation to maintain and respect the individual’s dignity and integrity. However, working within time limits and heavy workload leads to burnout and ethical insensitivity among nurses, and may challenge nurses’ options to act on the basis of ethical and moral grounds in the individual care situation.
Aim: The aim of this study is to describe and discuss ethical dilemmas described and experienced by nurses in clinical practice today.
Method: The study was performed as a literature review following the matrix method allowing to synthesize literature across methodological approaches. A literature search was performed, including relevant studies published between 2011 and 2016. A total of 15 articles were included and analyzed focusing on their description of ethical dilemmas.
Ethical consideration: We have considered and respected ethical conduct when performing a literature review, respecting authorship and referencing sources.
Results: The analysis revealed three themes, relating to important aspects of nursing practice, such as the nurse–patient relationship, organizational structures, and collaboration with colleagues. The findings are summarized in the following three themes: (1) balancing harm and care, (2) work overload affecting quality, and (3) navigating in disagreement. Ethically difficult situations are evident across settings and in very diverse environments from neonatal care to caring for the older people. Organizational structures and being caught in-between professional values, standardization, and busyness was evident, revealing the complexity of nursing practice and the diversity of ethical dilemmas, concerns, and distress experienced by clinical nurses.
Conclusion: Nursing practice is challenged by organizational structures and the development of the health care system, inhibiting nurses’ professional decision-making and forcing them to compromise basic nursing values.
Keywords
Clinical ethics, dilemmas, ethics of care/care ethics, literature review, nurses and disagreements,
professional ethics
1VIA University College, Denmark 2Aarhus University, Denmark 3Aarhus University Hospital, Denmark
Corresponding author(s):
Anita Haahr, VIA Health Promotion & Rehabilitation, Centre for research and development and School of Nursing, Hedeager 2,
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Introduction
Nursing practice is rapidly evolving, and patient pathways are becoming more efficient and cost-
effective. The last decades have seen growing complexity of the healthcare environment due to
advanced technological and medical developments as well as a stronger focus on standardization and the
logic of production that permeate today’s hospital cultures.1 This means that nurses not only have to
take care of the needs of patients and their families, they also face multiple demands from medical teams
and hospital management in their everyday work. The hallmark of nursing is a holistic approach whose
central values constitute an ethical obligation to maintaining and respecting the individual’s dignity and
integrity. As such, nursing is embedded in ethical and moral concerns. In their daily practices, nurses
make moral decisions, not just in situations concerning life and death, but also with respect to more
routine issues.2
Moral decisions are based on nurses’ ethical awareness and involve a complex process of observing,
analyzing, and weighing up the possible consequences of a choice where nurses are driven by the ideal
of care and the aim of “doing good.”3 For nurses, doing good means considering the patient’s well-
being, quality of care, and the patient’s dignity. In other words, the patient’s lifeworld is taken into
account. As stressed by Todres et al.,4 adopting a lifeworld perspective in caring requires that nurses
direct their attention to the patients’ lifeworld and their existential issues. This includes an existential
partnership that acknowledges differential levels of expertise and understanding between patient and
professionals.5 Thus, a caring practice is based on the patient as an expert in living with their illness.3–7
However, studies that address nurses’ experiences of moral issues in daily practice document that
pressure to work within time limits and manage a heavy workload add to burnout8 and ethical
insensitivity,2 thus compromising the lifeworld perspective in caring encounters. An inability to provide
comprehensive care due to shortage of staffs can also lead to nurses feeling powerless and resentful
toward hospitals.2 Nurses may work in high-pressure environments characterized by conflicts where
they face complex and ethically difficult situations.
Nurses’ decision-making in these ethically difficult situations must adhere to bioethical principles,
respect for autonomy, beneficence, non-maleficence, and justice.9 Respect for autonomy refers to each
individual’s personal values and beliefs and his or her right to make own choices regarding treatment
and care, based on individual preferences. Clinical healthcare professionals must ensure that patients can
make informed choices and act based on information. Beneficence refers to actions intended to benefit
others, whereas non-maleficence is the obligation not to do harm to others. All actions and decisions
taken with respect to patients’ treatment and care must therefore be based on a thorough evaluation of
what is most beneficial for the patient, taking the patient’s interests into account. The principle of justice
implies ethical decision-making and is formed on fairness and equality. Justice involves adhering to
universal rules where respect for autonomy, objectivity, and a positive mind-set are guiding norms.9 In
situations where treatment benefit is uncertain or patients and physicians/nurses have conflicting
interests, bioethical principles may provide poor guidance as they may be at variance with each other. In
these situations, nurses may experience an ethical dilemma. An ethical dilemma is defined as a situation
where a choice has to be made between competing values, and no matter what choice is made, it will
have consequences.10 Hence, a dilemma may be if the nurse is forced to choose between options that are
considered equally desirable or undesirable but may also occur when forced to compromise or act
against own professional values.
8200 Aarhus N. Email: [email protected]
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Studies show that a lack of congruence between the practice and ideals of care causes ethical
dilemmas for nurses.6,11–13 Holm et al.13 highlight that ethical dilemmas arise from conflicts among
values, norms, and interests and can be understood as the tension of knowing the “right thing to do, but
experiencing institutional or other constraints making it difficult to pursue the desired course of action”
(p. 403). Thus, the competing values of ethical dilemmas for clinical nurses mean that resolving these
dilemmas usually entails compromising personal and professional values, as well as compromising the
nurses’ ability to provide high-quality, compassionate care.11
The difficult conditions for care, optimized treatment schedules, and standardized regimes affecting
healthcare systems worldwide challenge nurses’ options to act on the basis of ethical and moral grounds
in individual care situations. The aim of this article is to describe and discuss ethical dilemmas
experienced by nurses in clinical practice today. We do so by analyzing ethical dilemmas that have been
outlined in recent empirical nursing studies.
Method
A review of the literature was conducted using the matrix method developed by Garrard.14 This
approach allows researchers to synthesize the literature on a specific topic, thereby capturing knowledge
and research from different methodological areas.14 We used this systematic approach to identify the
literature, irrespective of the methods used in the included studies. To avoid excluding important
sources, experiences, and topics, we chose an integrative approach that accommodated the inclusion of
studies with different methodologies.15 In searching for relevant literature displaying ethical dilemmas
as they appear in current clinical nursing practice, we reviewed literature from 2011 to 2016.
Search strategy
The search strategy encompassed an initial unstructured broad search, a computerized database search,
and a manual search. The former was undertaken with assistance from an information scientist, and we
searched the following databases: PubMed, CINAHL, Scopus, and SveMed+. We used the following
search terms: nursing, nursing care, ethical dilemmas, existential dilemma, empirical and moral distress.
Search terms were identified by screening relevant studies from the broad search. The search was
conducted using these MeSH words or major subject headings one by one and in combination. The
manual search consisted of a reference search. The database search resulted in 109 hits, and the manual
search added 1 article. Only articles written in English or Scandinavian languages were included.
Inclusion criteria
We included articles that reported clinical nurses’ experiences of ethical dilemmas, moral distress,
and/or ethically difficult situations in nursing practice.
The total number of identified articles was 110, which was subsequently reduced to 103 by removing
duplicates. The remaining articles were distributed between all four authors who performed a detailed
screening for relevance where studies that according to the title or abstract contained data relating to
ethical dilemmas were examined closely. In this process, excluding obviously irrelevant articles based
on title, language, and publication date, another 86 articles were excluded, and 17 eligible articles
remained. Any doubt about including the article was resolved by consensus discussion. Thus, in total, 15
articles were included for further analysis. See Figure 1 for a flowchart of the process.
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Ethical considerations
We have respected and followed ethical conduct for performing a literature review, by analyzing the
findings from the included studies with great caution and respect for the original context in which these
studies were written. All the included studies had obtained ethical approval or described ethical
considerations relevant to the study.
Analysis
The 15 articles were all read in full and were analyzed with respect to their descriptions of ethical
dilemmas. The articles were analyzed across the studies and over the years, looking for similarities and
discrepancies in content, methodology, and findings.14 Furthermore, the study design, results, and
conclusions were assessed.
The assessment focused on the information and content gained from the articles alone. Articles were
included if they addressed ethical dilemmas in nursing practice. Only peer-reviewed articles were
included and all papers were read thoroughly. However, to not miss out on important findings, articles
were not screened for quality and no articles were excluded because of lack of quality.16 Results from
the analysis formed the basis of the discussion and our concluding remarks (see Table 1).
Figure 1. PRISMA flow diagram.
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Results
The 15 original, empirical studies of nurses’ experiences of ethical dilemmas in their daily work were
analyzed and revealed a broad variety of experiences on the topic. The experiences related to three
important aspects of nursing practice: the nurse–patient relationship, organizational structures, and
collaboration with colleagues. Below, we summarize the findings with the aim of providing a detailed
account of the experiences of ethical dilemmas in nursing practice across the studies. The findings are
structured into three themes: (1) balancing harm and care, (2) work overload influences quality, and (3)
navigating in disagreement.
Balancing harm and care
Overall, what was most important for nurses was facilitating well-being and providing high-quality care
for the patients. However, in some situations, nurses were forced to act against what they considered to
be good and appropriate care, and this was experienced as stressful.21 For example, patients and
relatives could have preferences for care that conflicted with the nurses’ professional responsibilities.21
Also, physicians could plan treatment that collided with nursing values. In both situations, nurses
experienced that they had to do something they did not believe in. For example, when caring for
seriously ill patients, active treatment could continue even though it was obvious that the patient was
dying.18 In such situations, nurses could feel that they contributed to harming the patient and prolonging
a life that was not worth living. A similar situation could occur when caring for premature babies, where
caring efforts could be compared to torture when hope was no longer an option.19 In geriatric care,
physical restraint could be necessary to ensure the safety of the patient3 or in order to perform important
procedures. Before nurses applied restraint, they would try to prepare the patient for the difficulties he or
she was facing. Typically, nurses were reluctant to apply restraint immediately out of respect for the
person and his or her capacities.3 Nurses could also feel remorse when treating patients mechanically,18
adding to a feeling of harming the patient. Overall, performing procedures that were painful for patients
or having to deviate from what they considered appropriate standards of care was experienced as a great
burden by nurses.
Work overload influences quality
All nurses wanted to produce high quality of care, but quality was often affected by a lack of balance
between patient care and administrative duties.22 Nursing care was described by some nurses as a heavy
workload, and the heavy workload was considered the main cause of ethical insensitivity.2
Inability to provide comprehensive care due to shortage of staffs made the nurses feel powerless and
resentful toward hospitals.2 Furthermore, organizational norms forced nurses to provide care to greater
numbers of patients, and that affected the quality of patient care, in the nurses’ opinion.11 Moreover,
having to work continuously within time limits added to burnout.8
Having to provide care to more patients, a heavy workload, and providing care as quickly as possible
without sufficient time to provide comprehensive patient treatment caused distress in the nurses. That, in
turn, resulted in loss of concentration, which also affected the quality of the patient care.11
Shortage of staffs, lack of equipment, organizational issues, and policies are reported in most studies
as stressful. It was considered stressful if it was not possible to deliver the care that was identified as the
care and treatment needed.21 Furthermore, pressure to admit a greater number of patients than the
approved number of beds in units worried nurses. This worry was described as being due to
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administrative directives that were not deemed appropriate and conflicts between the needs of an
individual nurse and the unit.22 Thus, the different papers all reflected moral concerns for the quality of
care provided.12,20
Navigating in disagreement
Differences in competences and responsibility meant that nurses could have disagreements with
physicians. Often, the two groups had different strategies for treatment, and disagreements in the team
about the level of treatment could generate ethical dilemmas.18 Not being heard or having their opinions
ignored because of their lack of authority induced moral distress among nurses.2
The physicians had the mandate to revise a decision if the patient or next-of-kin asked for it,18 and
nurses had to follow this decision, even if they did not understand or support it.23 The included studies
also showed that nurses found it difficult when doctors made plans without involving patients. The
nurses then had to administer treatment that they did not wish to provide, for example, administering
aggressive treatment against their will because of physician or family member recommendations, and
being unable to provide satisfactory hospice care to terminally ill patients.11 In particular, when
disagreeing on treatment strategy, nurses complained that there was no time for discussion about
treatment philosophies; instead, it was mainly the biomedical perspective that was considered the
appropriate basis for treatment.
Discussion
This study identified three themes that reflect ethical dilemmas currently experienced by nurses in
hospital settings: balancing harm and care, work overload influences quality, and navigating in
disagreement. Although the clinical settings of the articles were very different, varying from neonatal
care to caring for older people in acute hospital, psychiatric care, and nursing homes, the findings
revealed that the three identified themes were evident in all the settings.
Balancing harm and care refers to difficult situations where the actions expected of nurses and the
care they more or less are forced to provide collide with their own professional convictions and values.
The findings reveal that such conflicts may cause both stress and remorse, whether it is caused by
disagreement with patients, relatives, physicians, as part of a necessary treatment strategy, or due to rigid
organizational structures. In this situation, nurses’ holistic view of the individual’s situation contributes
to increasing the nurses’ stress levels. Adopting a feminist and political perspective, Tronto23 argues that
how we think about care is deeply implicated in existing structures of power and inequality.23 Thus, for
Tronto, care is not only a moral concept but also a valuable political concept as it helps us rethink
humans as interdependent beings, and she argues that “an ethic of care remains incomplete without a
political theory of care” (p. 155).23 This ethics-of-care perspective thus adds to bioethical principles and
emphasizes holism and context. It calls upon nurses’ attentiveness, responsibility, and responsiveness
without regard to guidelines, principles, or rules.24–26 Hence, ethics of care refers to nurses’ clinical
wisdom and their moral competence.23,27–29 This perspective gives nurses a different view of a situation
than that of patients and physicians, and it may well contribute to nurses’ experiences of ethical
dilemmas in situations where they are challenged in balancing harm and care. We argue that these
personal qualities of a morally competent nurse are preconditions for an ethically sound practice. Benner
and Wrubel7 consider this ethical awareness to be an essential part of expert nursing practice and one
that should be carefully nourished. The conflict forces us to address these diverging values to prevent
burnout due to distress and, even more importantly, to help nurses articulate and argue for their
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professional perspectives on individual situations.
Organizational structure constitutes a particular aspect of the influence of work overload on quality.
Shortage of staffs, high patient turnover, and administrative tasks were all aspects of the experience of
being overloaded and unable to provide adequate care. One aspect is the demand for documentation.
Castner30 claims that “in an increasingly litigious culture of hyper-regulation, health care providers feel
pressured to focus on documentation rather than the administration of care” (p. 558). She highlights the
difficulty nurses experience when having to balance time spent at the bedside with “prudent charting.”30
Dierckx de Casterlé et al.31 found that nurses generally used conformist reasoning in ethical dilemmas at
the expense of creativity and critical reflection, which are key aspects of good clinical nursing care.32
Basically, what is missing is engagement with the individual patient and the patient’s particular
circumstances. Navigating in disagreements or being overloaded by work seems to lead to care of lower
quality and compromised nursing values which ultimately may also lead to compassion fatigue. When
nurses feel forced to act in ways that are at odds with their nursing beliefs and values, this not only
means poorer care but it also undermines the ethical and moral values that have guided nursing practice
as far back as Florence Nightingale.1 Furthermore, we argue that this not only threatens professional
identity of nurses but also impedes the development of the nursing profession.33
“Being overloaded by work” reflects today’s healthcare systems as infused by busyness and
effectiveness, and as being under the heavy influence of measurable values. The Norwegian Professor
Kari Martinsen34 argues that busyness has become a mode of being, and what characterizes busyness is
the urge to act quickly, to engage in hectic activities, and this occurs at the cost of being present in both
body and mind with the patient. In the analyzed studies, stress was experienced by nurses if it was not
possible to deliver the care that was identified as the care and treatment needed. Therefore, the nurse in
the mode of busyness is at risk of overlooking the patient’s appeal for help and need for care.34 As
patients’ need for care is fundamental, this leaves the nurse with burnout and maybe even the desire to
leave the profession. Therefore, the moral concerns highlighted in the studies have to be taken seriously.
The theme “Navigating in disagreement” brings to light one of the fundamental differences between
nurses and physicians. As physicians have formal responsibility for treatment of the patient, this could
mean that nurses have to follow prescriptions that they do not agree on. These situations were identified
as very difficult in the included studies. The nurses wished to be seen as equal collaborators with the
physicians and be recognized for and involved in planning treatment and care on the basis of their
particular knowledge of the patient. However, physicians made important decisions without involving
them. Honneth’s theory of recognition may elucidate this cooperative relationship.35 According to
Honneth,35 recognition is differentiated into three spheres of recognition: (1) the sphere of privacy, as
we know from family and friends; (2) the judicial sphere; and (3) the sphere of solidarity that includes
cultural, political, and work communities. Recognition within these three spheres constitutes an
ontogenetic step in the development of an individual, since it is necessary that the individual experiences
all three forms of recognition to be fully individuated. When it comes to cooperation between
professional groups, recognition in the sphere of solidarity is relevant. Honneth stresses that relating to
oneself necessarily involves experiencing recognition from others, since one’s relationship to oneself is
an inter-subjective process in which one’s attitude toward oneself emerges in one’s encounter with
another’s attitude toward oneself.35 In the included studies, it was difficult for the nurses to view
themselves as “valuable contributors to shared projects,” what is considered central to recognition in the
solidarity sphere. Formal differences in decision-making authority and the nurses’ experiences of being
overruled by physicians seemed to aggravate the nurses’ feeling of inferiority in the included studies.
The identified themes illustrate how nursing is an ethical practice. Bollig et al.17 divide ethical
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dilemmas into different types of dilemmas, described as everyday ethical issues and big ethical issues.
This is illustrated as an “ethical iceberg,” where big ethical issues are more visible than everyday ethical
issues, illustrated as being hidden under the water.17 Our findings support this differentiation of ethical
dilemmas, highlighting that hidden everyday dilemmas are experienced as most significant by nurses.
Also, Hopia et al.20 distinguish between ethical and non-ethical dilemmas. They define an ethical
dilemma “as a situation in which a choice has to be made between at least two options, none of which
resolves the situation in an ethically acceptable way” (p. 661) and they classify an ethical concern “as
an ethical problem that did not require an immediate choice by a health professional or a situation
where a health professional had questions about how to provide the best care to challenging patients or
information to patients families” (p. 667).21 Most of the non-dilemma concerns were related to
organizational issues, bioethical aspects, or lack of quality of care. However, in light of our findings, the
term non-dilemma is not appropriate to illustrate and acknowledge the stress and ethical dilemma
experienced due to organizational structures. On the contrary, our findings emphasize that organizational
structures and work environments are very much the source of ethical dilemmas experienced at work,
especially in situations where nurses cannot act in accordance with their own professional convictions
and values. According to Choe et al.,2 moral distress arises from ethical dilemmas and refers to
“traditional negative stress symptoms that occur due to situations that involve ethical dimensions and
where the healthcare provider feels he or she is not able to preserve all interests and values at stake” (p.
1685). Green et al.19 refer to moral distress as painful feelings and/or psychological disequilibrium that
occurs when institutionalized obstacles make nurses unable to translate their conscious moral choices
into moral action. As illustrated by the three themes, evidence-based knowledge and monetary aspects
were prioritized over ethical aspects.
Thus, morality was separated from practice and caring, illustrating that the complexity of nursing
practice is closely linked to nurses being in an in-between position. All themes illustrate how nurses
navigate in a field between the physician, technological knowledge, well-being of the patient, hospital
regulations, time schedules, and the discipline of nursing. Furthermore, the themes show that this places
nurses in a very difficult position where ethical dilemmas are unavoidable as conflicts easily occur due
to the power structures of the hospital. According to Bishop and Scudder,33 this in-between stance is a
position that is both essential and unique to nursing. Working in this in-between stance places nurses in a
position uniquely suited to fostering the patient’s well-being, as nurses, due to the 24-h care, usually
relate much more closely to the patients than anyone else.33 Bishop and Scudder argue that although this
in-between position is difficult to manage, it is also a privileged one for ensuring that team decisions are
ethical.
Concluding remarks
This article reveals that regardless of nurses’ individual competences, organizational structures, the work
environment, political agendas, and efficient hospital cultures impact strongly their abilities to act
according to their professional ethical and moral convictions.
The findings reflect typical dilemmas embedded in the nursing discipline across different settings
and illustrate the difficult, complicated, and ambiguous situations that nurses face in their daily practice.
One important aspect that seems to be overlooked but is nevertheless essential to highlight is that the
dilemmas experienced seemed to be more related to ethical concerns than ethical dilemmas. This finding
underlines the importance of addressing these concerns and examining how today’s organizational
structures affect the possibility of providing nursing care that is consistent with basic nursing values.
Numerous guidelines and standardized regimens leave nurses with moral and ethical challenges in their
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daily practice. Standardization has inhibited nurses’ professional decision-making and impeded their
ability to provide the care they find most appropriate, forcing them to compromise their basic
professional nursing values.
Conflict of interest
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication
of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iD
Anita Haahr https://orcid.org/0000-0002-8373-176X
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