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The moral enterprise in intensive care nursing
Ersta Sköndal University College, Department of Health Care Sciences.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The aims of this thesis were to explore nurses' experiences of stress in the ICU (I), to analyze experiences of moral concerns in intensive care nursing from the perspective of relational ethics (II), to describe the synthesis of the concept of moral stress and to identify preconditions for moral stress (III) and to analyse and describe lived experiences of support in situations characterized by critical care situations and moral stress in intensive care (IV).The design was exploratory and descriptive. Material in studies I, II and IV consisted of interviews with intensive care nurses (10 head nurses and 26 staff nurses) employed in general, thoracic and neonatal intensive care units in five hospitals located in different parts of Sweden. The material in study III data from two studies of professional issues in nursing were used for the analysis: one concerned psychiatric nursing and the other was the previously referred study I.In study I qualitative content analysis and descriptive interpretation was used in the analysis. The main theme 'stress induced by dissonant imperatives' formulated in the analysis. Dissonant imperatives are composed of the four sub-themes: 1) controlled by the working situation - needing to be in control, 2) constrained by prioritisation - wanting to do more, 3) lacking authority to act - knowing that something should be done, and 4) professional distance - interpersonal involvement. In study II qualitative content analysis and descriptive interpretation were used in the analysis. A main theme was formulated, 'caring about-caring for: tensions between moral obligations and work responsibilities in intensive care nursing'. Five sub-themes were formulated 1) believing in a good death, 2) knowing the course of events, 3) feelings of distress, 4) reasoning about the physicians and 5) expressing moral awareness. In the study III a hypothetical-deductive method was used. The findings indicate that moral stress is independent of context-given specific pre-conditions: 1) nurses are morally sensitive to the patient's vulnerability, 2) nurses experience external factors preventing them from doing the best for the patient, and 3) nurses feel that they have no control over the situation. In the study IV an interpretive method was used. The first level of analysis of data identified contextual factors, such as type and purpose of support and working conditions. Thereafter five tentative interpretations were revealed: 1) receiving organised support is a matter of self-determination, 2) whether to participate or to be off duty is experienced mutually as exclusive, 3) dealing with moral stress is experienced as a private matter, 4) colleagues managing moral stress serve as models in stress support, and 5) not being able to deal with moral stress urges one to seek outside support. A comparison of these interpretations identified three major themes: availability, accessibility and receptivity of support. The main interpretation of data was: "lived experience of moral stress support involves an interconnectedness between structural and existential factors".A comprehensive understanding was formulated using the four studies (I, II, III and IV). Moral stress was found to be influential on the caring competence. Conflicts between different competences were found leading to a shift in focus away from the patients leading to a possible decrease in the caring competence. Moreover, the subtle resistance among nurses toward participation in organized moral stress support may obstruct the development of nurses' caring competence. Accordingly, imbalance, due to moral stress, between different competences hinders the development of collectively shared caring competence.

Place, publisher, year, edition, pages
Stockholm: Karolinska University Press , 2004. , 69 p.
Keyword [en]
caring competence, hermeneutics, intensive care nursing, moral stress, qualitative content analysis, stress support, ethics, nursing, intensive care units ethics, morals, nurses psychology, burnout, professional psychology, stress
National Category
Nursing
Identifiers
URN: urn:nbn:se:esh:diva-486ISBN: 91-7349-942-0 (print)OAI: oai:DiVA.org:esh-486DiVA: diva2:329511
Public defence
2004-06-09, Hörsal 1, Karolinska Institutet, Alfred nobels allé, Huddinge, 13:00
Opponent
Supervisors
Available from: 2010-07-12 Created: 2010-07-12 Last updated: 2011-04-06Bibliographically approved
List of papers
1. Nurses' lived experiences of moral stress support in the intensive care context.
Open this publication in new window or tab >>Nurses' lived experiences of moral stress support in the intensive care context.
2006 (English)In: Journal of Nursing Management, ISSN 0966-0429, E-ISSN 1365-2834, Vol. 14, no 5, 405-13 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to analyse and describe lived experiences of support in situations characterized by critical care situations and moral stress in intensive care nursing. An exploratory interpretative study was conducted. Data consisted of interviews with 36 nurses from different types of intensive care units. The first level of analysis of data identified contextual factors, such as type and purpose of support and working conditions. On the next level of analysis five tentative interpretations were identified: (1) receiving organized support is a matter of self-determination, (2) whether to participate in organized support or to be off duty are experienced as mutually exclusive, (3) dealing with moral stress is experienced as a private matter, (4) colleagues managing moral stress serve as models in stress support and (5) not being able to deal with moral stress urges one to seek outside support. A comparison of these interpretations identified three major themes: availability, accessibility and receptivity of support. The main interpretation and conclusion were: lived experience of moral stress support involves an interconnectedness between structural and existential factors. Thus, adequate moral stress support presupposes an allowable professional climate and access to caring supervision.

National Category
Nursing
Identifiers
urn:nbn:se:esh:diva-109 (URN)10.1111/j.1365-2934.2006.00631.x (DOI)16787476 (PubMedID)
Available from: 2010-05-14 Created: 2010-05-14 Last updated: 2011-04-06Bibliographically approved
2. Dissonant imperatives in nursing: a conceptualization of stress in intensive care in Sweden.
Open this publication in new window or tab >>Dissonant imperatives in nursing: a conceptualization of stress in intensive care in Sweden.
2001 (English)In: Intensive & Critical Care Nursing, ISSN 0964-3397, E-ISSN 1532-4036, Vol. 17, no 4, 228-36 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to explore nurses' experiences of stress within the context of intensive care. The theoretical perspective for the study builds on a cognitive-phenomenological-transactional theory of stress and coping and the theory of cognitive dissonance. Respondents were 36 registered nurses recruited from 10 intensive care units (general, neonatal and thoracic units). Their experience as nurses ranged from one to 32 years. These intensive care units had similar structural characteristics, namely a high working pace, advanced technology, constrained finances, frequent reorganizations, a shortage of registered nurses and all were filled to overcapacity. Data were collected in open-ended interviews that were audio-taped and transcribed. A content analysis identified four contradictory themes: (1) controlled by the work situation--needing to be in control; (2) constrained by prioritization--wanting to do more; (3) lacking the authority to act--knowing that something should be done; and (4) professional distance--interpersonal involvement. These four themes were synthesized at a higher level of abstraction into a main theme: stress induced by dissonant imperatives, which conceptualizes nursing stress in the intensive care unit. In conclusion, dissonant imperatives might lead to stress in intensive care nursing.

National Category
Psychology
Identifiers
urn:nbn:se:esh:diva-112 (URN)10.1054/iccn.2000.1588 (DOI)11868731 (PubMedID)
Available from: 2010-05-14 Created: 2010-05-14 Last updated: 2011-04-06Bibliographically approved
3. Caring about--caring for: moral obligations and work responsibilities in intensive care nursing.
Open this publication in new window or tab >>Caring about--caring for: moral obligations and work responsibilities in intensive care nursing.
2004 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 11, no 1, 63-76 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to analyse experiences of moral concerns in intensive care nursing. The theoretical perspective of the study is based on relational ethics, also referred to as ethics of care. The participants were 36 intensive care nurses from 10 general, neonatal and thoracic intensive care units. The structural characteristics of the units were similar: a high working pace, advanced technology, budget restrictions, recent reorganization, and shortage of experienced nurses. The data consisted of the participants' examples of ethical situations they had experienced in their intensive care unit. A qualitative content analysis identified five themes: believing in a good death; knowing the course of events; feelings of distress; reasoning about physicians' 'doings' and tensions in expressing moral awareness. A main theme was formulated as caring about--caring for: moral obligations and work responsibilities. Moral obligations and work responsibilities are assumed to be complementary dimensions in nursing, yet they were found not to be in balance for intensive care nurses. In conclusion there is a need to support nurses in difficult intensive care situations, for example, by mentoring, as a step towards developing moral action knowledge in the context of intensive care nursing.

National Category
Nursing
Identifiers
urn:nbn:se:esh:diva-110 (URN)14763651 (PubMedID)
Available from: 2010-05-14 Created: 2010-05-14 Last updated: 2011-04-06Bibliographically approved
4. Moral stress: synthesis of a concept
Open this publication in new window or tab >>Moral stress: synthesis of a concept
2003 (English)In: Nursing Ethics, ISSN 0969-7330, E-ISSN 1477-0989, Vol. 10, no 3, 312-322 p.Article in journal (Refereed) Published
Abstract [en]

The aim of this article is to describe the synthesis of the concept of moral stress and to attempt to identify its preconditions. Qualitative data from two independent studies on professional issues in nursing were analysed from a hypothetical-deductive approach. The findings indicate that moral stress is independent of context-given specific preconditions: (1) nurses are morally sensitive to the patient's vulnerability; (2) nurses experience external factors preventing them from doing what is best for the patient; and (3) nurses feel that they have no control over the specific situation. The findings from this analysis are supported by recent research on stress in the workplace but differ that the imperatives directing work are moral in nature. Stress researchers have found that persons who experience that they have no control over their work situation and at the same time experience high demands may be prone to cardiovascular diseases. An important question raised by this study is whether moral stress should be recognized as a health risk in nursing. Further research is required in order to generate intervention models to prevent or deal with moral stress.

National Category
Health Sciences
Identifiers
urn:nbn:se:esh:diva-101 (URN)10.1191/0969733003ne608oa (DOI)12762464 (PubMedID)
Available from: 2010-05-17 Created: 2010-05-10 Last updated: 2014-11-04Bibliographically approved

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