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Ethically difficult situations in hemodialysis care: nurses' narratives
Umeå University, Faculty of Medicine, Department of Nursing.
Umeå University, Faculty of Medicine, Department of Nursing.
County Council of BD, Sweden.
Umeå University, Faculty of Medicine, Department of Clinical Sciences, Psychiatry.
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2015 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 22, no 6, 711-722 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Providing nursing care for patients with end-stage renal disease entails dealing with existential issues which may sometimes lead not only to ethical problems but also conflicts within the team. A previous study shows that physicians felt irresolute, torn and unconfirmed when ethical dilemmas arose.

RESEARCH QUESTION: This study, conducted in the same dialysis care unit, aimed to illuminate registered nurses' experiences of being in ethically difficult situations that give rise to a troubled conscience.

RESEARCH DESIGN: This study has a phenomenological hermeneutic approach.

PARTICIPANTS: Narrative interviews were carried out with 10 registered nurses working in dialysis care.

ETHICAL CONSIDERATIONS: The study was approved by the Ethics Committee of the Faculty of Medicine, Umeå University.

RESULTS: One theme, 'Calling for a deliberative dialogue', and six sub-themes emerged: 'Dealing with patients' ambiguity', 'Responding to patients' reluctance', 'Acting against patients' will', 'Acting against one's moral convictions', 'Lacking involvement with patients and relatives' and 'Being trapped in feelings of guilt'.

DISCUSSION: In ethically difficult situations, the registered nurses tried, but failed, to open up a dialogue with the physicians about ethical concerns and their uncertainty. They felt alone, uncertain and sometimes had to act against their conscience.

CONCLUSION: In ethical dilemmas, personal and professional integrity is at stake. Mistrusting their own moral integrity may turn professionals from moral actors into victims of circumstances. To counteract such a risk, professionals and patients need to continuously deliberate on their feelings, views and experiences, in an atmosphere of togetherness and trust.

Place, publisher, year, edition, pages
Sage Publications, 2015. Vol. 22, no 6, 711-722 p.
Keyword [en]
Dialogue, dialysis care, ethics, narratives, nursing, troubled conscience
National Category
Nursing
Identifiers
URN: urn:nbn:se:umu:diva-97927DOI: 10.1177/0969733014542677ISI: 000360898200009PubMedID: 25106455OAI: oai:DiVA.org:umu-97927DiVA: diva2:782757
Available from: 2015-01-22 Created: 2015-01-09 Last updated: 2017-12-05Bibliographically approved
In thesis
1. Experiences of being in ethically difficult care situations and an intervention with clinical ethics support
Open this publication in new window or tab >>Experiences of being in ethically difficult care situations and an intervention with clinical ethics support
2016 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Studies show that healthcare professionals often experience ethical difficulties in their relations with patients, relatives, and other professionals and in relation to organisational issues, and these can sometimes be difficult to handle. Failing to act or to relate in accordance with one’s values for what is good and right might cause a troubled conscience that is connected to feelings of guilt and ill-being. Ethical issues related to the care of patients with end-stage renal disease have been described, but no studies in this context have been found that explore registered nurses’ (RNs’) and physicians’ experiences of being in ethically difficult situations that give rise to a troubled conscience. The importance of communicating ethical issues in order to understand and handle ethically difficult care situations has been emphasized. Various forms of clinical ethics support (CES) have been described and evaluated, but studies on the communication processes and the organisation of CES interventions are sparse and no study describing a CES intervention based on Habermas’ theory of communicative action has been found.

Aim: The overall aim was to increase our understanding about being in ethically difficult care situations and about how communication concerning ethical issues in healthcare can be promoted. More specifically, the aim of studies I and II was to illuminate experiences of being in ethically difficult situations giving rise to a troubled conscience among RNs and physicians, while studies III and IV aimed to describe the communication of value conflicts (III) and the organisation and performance of a CES intervention (IV).

Methods: In studies I and II narrative interviews with ten RNs (I) and five physicians (II), were performed in a dialysis care context. The interviews were analysed using a phenomenological hermeneutic approach. In studies III and IV, eight audio- and video-recorded and two audio-recorded sessions of the CES intervention, were conducted and sorted by the data tool Transana and analysed in accordance with a qualitative content analysis (III) and a qualitative concept- and data-driven content analysis (IV).

Results: The RNs’ narratives (I) resulted in the theme ‘Calling for a deliberative dialogue’. Their narratives expressed feelings of uncertainty, solitude, abandonment, and guilt in complex and ambiguous ethically difficult situations. The narratives concerned the value conflict between preserving life by all means and preserving life with dignity. The physicians’ narratives (II) resulted in the themes ‘Feeling trapped in irresolution’ and ‘Being torn by conflicting demands’. Their narratives expressed feelings of uncertainty, solitude, abandonment and guilt related to the obligation to make crucial decisions and in situations when their ideals and the reality iii clashed. The analysis of the communication of value conflicts during the CES intervention inspired by Habermas’ theory of communicative action (study III) revealed a process of five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, revelation of the value conflict, enhancing realistic expectations of the patients and relatives, and seeing opportunities to change the situation instead of obstacles. The CES intervention (study IV) was organised as a framework with a given structure and an openness for variations to facilitate communicative action. Three courses of actions to reach a communicative agreement were identified and concerned the approach to achieve a permissive communication, opening up for extended views, and enhancing mutual understanding (IV).

Conclusion: The results show that both RNs and physicians expressed feelings of uncertainty abandonment and loneliness in similar ethically difficult situations but from different points of view. They struggled with the same value conflicts and feelings, but they did not share their struggles with each other. The lack of communication and confirmation led to distrust and increased feelings of uncertainty. The CES intervention, inspired by Habermas’ theory of communicative action, offered the possibility of dealing with experiences of ethically difficult care situations. In the permissive atmosphere, the professionals helped each other to balance their ambiguity, frustrations, and powerlessness and came to an agreement about how to handle the value conflicts and how to act. The findings from this CES intervention constitute a step towards a CES method that is clearly described so that leaders can be educated and extended intervention studies with different kinds of data can be conducted in order to further develop knowledge about how to promote an inter-professional dialogue about ethical difficulties.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2016. 54 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1841
Keyword
Care ethics, clinical ethics support, ethically difficulties, healthcare professionals, inter-professional communication, narratives
National Category
Nursing
Research subject
Caring Sciences
Identifiers
urn:nbn:se:umu:diva-126973 (URN)978-91-7601-556-8 (ISBN)
Public defence
2016-11-18, Vårdvetarhusets aula, Petrus Laestadius väg, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2016-10-28 Created: 2016-10-24 Last updated: 2016-10-28Bibliographically approved

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