Encountering ethical problems and moral distress as a nurse : Experiences, contributing factors and handling

The aim of this thesis was to explore and describe what nurses find ethically problematic and morally distressing in their work, the factors contributing to the arising of ethically problematic situations and the actions reported taken in order to handle them, thus creating an ethical climate. Descriptive as well as correlational and exploratory designs were employed in the four papers on which this thesis is based. A total of 283 nurses from 21 acute care wards at four Swedish hospitals participated. Interviews were analyzed using qualitative content analysis and the critical incident technique, and questionnaires were analyzed using descriptive and non-parametric statistics. The nurses described ethical problems and moral distress related to decision making about life-sustaining treatment, but also when they experienced difficulties in preserving a patient’s integrity and when they could not give care that was necessary and safe. Inadequate communication between healthcare staff, the physicians’ ways of handling potentially ethically problematic situations and patients’ poor state of health, which hindered their participation in decisions concerning them, were some of the factors that could contribute to the rise of an ethically problematic situation. Among the actions described as being used to handle ethical problems and moral distress, some were explicitly stated to promote a positive ethical climate, i.e. a perceived positive handling of ethical issues. These were supporting each other in the working group, using policies and routines as help, giving care based on the needs of patients and their next of kin and daring to speak out, thus contributing to setting a standard for behavior. Having the need for explanations and information satisfied and working as a team also promoted a positive ethical climate. In conclusion, the professional role of being a nurse seems to be of importance not only when it comes to what situations are experienced as ethically problematic and morally distressing, but also concerning what factors may contribute to the rise of them. Perceiving a positive ethical climate may mediate these experiences