Moral Problems Experienced by Nurses when Caring for Terminally Ill People: a literature review

Abstract

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses' perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment.

Work Engagement, Moral Distress, Education Level, and Critical Reflective Practice in Intensive Care Nurses

“…It is experienced by RNs in the following variety of care provision settings: medical surgical/acute care (Corley, Minick, Elswick, & Jacobs, 2005;Storch, Rodney, Pauly, Brown, & Starzomski, 2002;Rice, Rady, Hamrick, Verheijde, & Pendergast, 2008;Verhaeghe, Vlerick, De Backer, Van Maele & Gemmel, 2008;Wilkinson, 1987/88, Zuzelo, 2007, home care (Liaschenko, 1995), occupational health (Corley, Elswick, Gorman, & Clor, 2001), military (Fry, Harvy, Hurley & Foley, 2002), cardiology and hematology (Kälvemark, Höglund, Hansson, Westerholm, & Arnetz, 2004), psychiatry (Forchuk, 1991;Liaschenko, 1995), peri-operative (Von Post, 1998), palliative care (Georges & Grypdonck, 2002), pediatrics, diabetic educators, rehabilitation, and nephrology (Redman & Fry, 2000), dialysis, skilled/long term care, maternity, acute rehabilitation, and telemetry (Zuzelo, 2007) and critical care/neonatal intensive care (Corley, Elswick, Gorman & Clor, 2001;Hamric & Blackhall, 2007;Cronqvist, Theorell, Burns & Lützén, 2004;Gutierrez, 2005;Hefferman & Heilig, 1999;Meltzer & Huckabay, 2004;Mobley, Rady, Verheijde, Patel & Larson, 2007;Sundin-Huard & Fahy, 1999;Verhaeghe, Vlerick, De Backer, Van Maele, & Gemmel, 2008, Zuzelo, 2007.…”

“…Unfortunately, in regards to the management of ethical/moral issues, powerlessness (versus empowerment) is an experience common to nurses (Erlen & Frost, 1991;Georges & Grypdonck, 2002;Gutierrez, 2005;Holly, 1993;Sundin-Huard & Fahy, 1999;Zuzelo, 2007). Eighty-four percent of medical surgical and critical care nurses describe themselves as ineffective and "powerless" (Erlen & Frost, 1991, pp.…”

“…Bureaucratic constraints (institutions) force obedience (perceived immoral action) upon nurses (valuable assets), who then may experience moral distress, which then contributes to nurses' decisions to (1) leave a position, (2) exit the profession or (3) avoid patient care (loss of valuable assets) (Corley, Elswick, Gorman & Clor, 2001;Corley, Minick, Elswick & Jacobs, 2005;Georges & Grypdonck, 2002;Gutierrez, 2005;Hamric & Blackhall, 2007;Millette, 1994;Wilkinson, 1987/88). In relation to moral distress, 15-50% of nurses decide to leave a position (Corley, et al, 2001(Corley, et al, , 2005Wilkinson, 1987Wilkinson, , 1988, 17-50% leave (or consider to leave) the profession (Hamric & Blackhall, 2007;Millette, 1994) and some nurses implement the common, but unsuccessful, coping behavior of avoiding patients (Georges & Grypdonck, 2002;Gutierrez, 2005;Wilkinson, 1987/88).…”

“…In relation to moral distress, 15-50% of nurses decide to leave a position (Corley, et al, 2001(Corley, et al, , 2005Wilkinson, 1987Wilkinson, , 1988, 17-50% leave (or consider to leave) the profession (Hamric & Blackhall, 2007;Millette, 1994) and some nurses implement the common, but unsuccessful, coping behavior of avoiding patients (Georges & Grypdonck, 2002;Gutierrez, 2005;Wilkinson, 1987/88).…”

“…Although there is currently limited evidence to directly link nurses' moral distress to patient satisfaction, quality of care, or patient outcomes, it is perhaps appropriate to suggest distancing (or disengagement) caused by moral distress contributes to the abundance of evidence which suggests "nurses do not always practice in ways persons cared for consider helpful" (Mitchell & Bournes, 2006, p. 118 (Corley, Minick, Elswick & Jacobs, 2005;Cronqvist, Theorell, Burns & Lützén, 2004;Erlen & Frost, 1991;Fry, Harvey, Hurley & Foley, 2002;Georges & Grypdonck, 2002;Hamric & Blackhall, 2007;Hart, 2005;Hefferman & Heilig, 1999;Kälvemark, Höglund, Hansson, Westerholm & Arnetz, 2004;Martin, 1989;Penticuff & Walden, 2000;Redman & Fry, 2000;Storch, Rodney, Pauly, Brown & Starzomski, 2002;Sundin-Huard & Fahy, 1999;Von Post, 1998) and (2) hierarchical work structures, (i.e., distrust of and fear of retribution from hospital leadership) (Erlen & Frost, 1991;Gutierrez, 2005;Hefferman & Heilig, 1999;Martin, 1989;Millette, 1994;Penticuff & Walden, 2000;Redman & Fry, 2000;Storch, et al, 2002;Sundin-Huard & Fahy, 1999, Wilkinson, 1987. Both of these are briefly summarized in the following paragraphs.…”