29-05-2014, 10:34 AM
Ethical issues experienced by intensive care unit nurses in everyday practice
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Abstract
This research aims to identify the ethical issues perceived by intensive care nurses in their everyday practice.
It also aims to understand why these situations were considered an ethical issue and what interventions/
strategies have been or are expected to be developed so as to minimize them. Data were collected
using a semi-structured interview with 15 nurses working at polyvalent intensive care units in 4 Portuguese
hospitals, who were selected by the homogenization of multiple samples. The qualitative content analysis
identified end-of-life decisions, privacy, interaction, team work, and health-care access as emerging ethical
issues. Personal, team, and institutional aspects emerge as reasons behind the experience of these issues.
Personal and team resources are used in and for solving these issues. Moral development and training are
the most significant strategies.
Introduction
Due to the complexity of the clinical situation of intensive care unit (ICU) inpatients and the technological
advances in these settings, nurses’ clinical decisions in their daily practice have become increasingly more
complex, requiring the use of different types of knowledge to protect and respect the dignity of the human
being.
The recognition of ethics as a foundation for clinical practice, the acknowledgement of new rights, an
unlimited array of health-care choices, economic issues, and changes in social and family systems have shed
̆ lu and
light on ethical issues, especially in terms of health care for critically ill patients (Melia apud C
̧ obanog
Algier and Woodrow).1,2
While nurses gain more autonomy and, consequently, more responsibilities, they experience more
difficulties in clinical practice, which is particularly significant in an ICU.3 We are in a field where there
are areas with some ambiguity and/or overlapping in terms of the actions of the professional groups,
where the suffering and limitations of human life are confronted. Making quick decisions adapted to the
situation in this area of lack of certainties, convictions, and clear and defined procedures for action creates
discomfort, danger, and ethical issues between professionals.
Conceptual reference framework
There are ethical and moral issues in the clinical practice in every health-related profession, both because of
the interaction among professionals and the interaction with patients. There are potentially different values
and beliefs, which make care options potentially different.4 Nowadays, society is better informed and edu-
cated and has higher expectations regarding care, which, according to Melia,4 constitutes a reason for dis-
cussion and research in the domain of ethics.
Today’s health-care environment is driven, on the one hand, by the provision of high-quality care and, on
the other hand, by cost management with diminishing resources. According to Ulrich et al.,5 nurses seem to
be doing more and more with these limited resources, but even when they do their best, they may not feel
that they have done it well enough.5
These aspects are transversal in health care, and they are very significant in intensive care because, due to
the great technological advances,6 in their final hours patients are still surrounded by multiple equipment
and therapeutics which characterize these units.1 Death, which involves prolonged suffering, away from
loved ones, is still one of these patients’ fears.
Data collection
The data collection technique used was the semi-structured interview. Interviews provide flexibility and
allow the interviewer to explore a wide range of topics, both reformulating and further developing them.
In addition, the participant has the opportunity to organize their thought process and, with the researcher,
explore topics during the interaction established by the interview, as suggested by Flick.9 A script was
drawn up for the interviews, which was divided into three parts. The first part is aimed at presenting the
study and characterizing the sample. The second part is composed of questions which describe or exemplify
the notion of ethical constraint or conflict in the workplace, the resources used, as well as the problem-
solving strategies. The third part included an open question in which the participant was asked to refer
an aspect which he/she considered relevant to be reported. It was also aimed at negotiating data validation
and thanking for the participation in the study. This tool was used in a flexible manner and depended on the
interaction established.
Ethical considerations
Participation was requested through personal and direct contact, in which researchers explained the aim of
the individual’s participation, as well as the object and the motivations underlying the study. During this
first contact, the participants’ collaboration was requested, informed consent was obtained, and the time and
venue for the interview were scheduled. It was agreed that all information regarding the participants’ pro-
fessional institution as well as any information which could possibly identify them would remain confiden-
tial. This was done so as not to hinder the interviewees. The interviews were conducted outside work hours
and workplace. The sample was composed of 15 nurses from 4 Portuguese hospitals working in polyvalent
ICUs: 7 women and 8 men, with a mean age of 34 years (25–43 years).
Conclusion
These findings provide a set of conclusions related to the ethical issues perceived by nurses when caring for
a critically ill patient.
Decision making in the context of intensive care is complex because the person’s clinical status places
time demands on nurses. For many participants, this situation is worsened by the fact that there is no holistic
view of the person and the benefit of medium- and long-term treatment is not discussed, thus focusing only
on the immediate situation, without including what is significant to the patient.
Following common guidelines is not a standardized practice among professionals, nor is the global anal-
ysis of the situations involving the multiprofessional team and the family members.
Regardless of how long they have been exercising their profession, participants recognized that they do
not critically reflect upon the issues posed by health-care provision. They also revealed that there is no con-
ceptual discussion, neither individual nor more general, on the concepts underlying clinical practice in the
ethical domain.
They have the feeling that there are no specific ethical issues in their context. However, they consider
that end-of-life decisions, privacy, interaction between nurse/patient and/or family, team work, and access
to care arise in their daily life.
Gender differences were found: male nurses place more value on an ethics of justice, whereas female
nurses place more value on an ethics of caring. In the latter, privacy emerges as a source of restlessness
because nurses realize how difficult it is to preserve and respect the patient’s intimacy and keep the infor-
mation confidential.