Original Manuscript
A study of nurses’ ethical climate perceptions: Compromising in an uncompromising environment
Nursing Ethics 1–12 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014564101 nej.sagepub.com
Anne Humphries and Martin Woods Massey University, New Zealand
Abstract Background: Acting ethically, in accordance with professional and personal moral values, lies at the heart of nursing practice. However, contextual factors, or obstacles within the work environment, can constrain nurses in their ethical practice – hence the importance of the workplace ethical climate. Interest in nurse workplace ethical climates has snowballed in recent years because the ethical climate has emerged as a key variable in the experience of nurse moral distress. Significantly, this study appears to be the first of its kind carried out in New Zealand. Aim/objective: The purpose of this study was to explore and describe how registered nurses working on a medical ward in a New Zealand hospital perceive their workplace ethical climate. Research design/participants/context: This was a small, qualitative descriptive study. Seven registered nurses were interviewed in two focus group meetings. An inductive method of thematic data analysis was used for this research. Ethical considerations: Ethics approval for this study was granted by the New Zealand Ministry of Health’s Central Regional Health and Disability Ethics Committee on 14 June 2012. Findings: The themes identified in the data centred on three dominant elements that – together – shaped the prevailing ethical climate: staffing levels, patient throughput and the attitude of some managers towards nursing staff. Discussion: While findings from this study regarding staffing levels and the power dynamics between nurses and managers support those from other ethical climate studies, of note is the impact of patient throughput on local nurses’ ethical practice. This issue has not been singled out as having a detrimental influence on ethical climates elsewhere. Conclusion: Moral distress is inevitable in an ethical climate where the organisation’s main priorities are perceived by nursing staff to be budget and patient throughput, rather than patient safety and care. Keywords Ethical climate, medical nursing, moral distress, nursing ethics, thematic analysis
Corresponding author: Anne Humphries. Email: [email protected]
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Introduction Although unseen, the ethical climate of any workplace exerts a powerful and pervasive influence on the ethical behaviour of the people who work there. It is particularly significant for nurses because the nursing profession was founded on ‘the moral premise of caring, and the belief that nurses have a commitment to do good’ (p. 9).1 Nursing is an inherently moral endeavour. Consequently, the prevailing workplace ethical climate has a major and far-reaching effect on nurses and their patients, because of its pivotal role in either facilitating or constraining nurses’ ethical practice. The purpose of this small study was to explore and describe how registered nurses working on a medical ward in a New Zealand hospital perceive their workplace ethical climate. The hospital provides a range of specialist secondary and regional services to a large city- and regional-based population. The medical ward has 37 beds, distributed among three discrete wings. Although research into nurse moral distress within the New Zealand context is emerging,2 it appears that the ethical climates of nurse workplaces in this country have not been explored prior to this study. The dual objective for doing this study was to generate interest in this important phenomenon within the local setting, while adding to the small – but growing – body of nursing ethics literature in New Zealand.
Background and significance of the study In the nursing literature, ethical climate refers to the shared perceptions of organisational practices surrounding ethical decision-making and reflection, including issues of power, trust and human interaction.3,4 Interest in this concept has grown considerably in recent years because the workplace ethical climate has emerged as a key factor in the experience of nurse moral distress.4–8 Negative climate antecedents are therefore of most concern because these can precipitate moral distress. Moral distress was originally conceptualised by Jameton,9 who described it as occurring when ‘one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (p. 6). Wilkinson10 later expanded upon this definition by noting the ‘psychological disequilibrium and negative feeling state’ (p. 16) that follows when an individual makes a moral decision, but cannot follow it through, due to situational constraints. It is associated with various physical and psychological symptoms,10 including emotional exhaustion, which is linked to burnout.11 More recently, moral distress was defined as an umbrella or cluster concept, capturing the experiences of individuals who are morally constrained.12 This definition allows for the fact that moral constraints can be specific to the individual (internal), or specific to the particular workplace (external). In the New Zealand context, inferences concerning ethical climates in healthcare workplaces can be drawn particularly from emerging New Zealand research on moral distress. For instance, preliminary findings from the first national study of nurse moral distress in New Zealand2 indicate that almost half of the 412 hospital-based respondents had considered leaving their current job as a result of moral distress in the workplace. Other local studies in nursing ethics refer indirectly to the impact of workplace ethical climates. One, concerning nurse managers’ ethical conflict with their employing organisations,13 refers to conflicts being caused by the ‘duality of professional and organisation values that their roles encompass’ (p. 114). Another local study, concerning the ethical practice of eight newly graduated nurses working in mental health,14 refers to factors affecting participants’ ethical practice, such as ‘disempowering and difficult relationship problems’ (p. 96). In another study, Vallance15 examined the undergraduate ethics preparation for practice of nine new graduate nurses. In making the transition from ‘ideal’ to ‘real’ in ethical terms, participants in that study had to refocus their own ‘ethical perspective’ and, in doing so, sacrificed their ‘ethical ideals’ as a result of contextual constraints within the workplaces where they were sent on placement. A further study by Woods16 explored the moral decision-making of experienced nurses and found that the healthcare 2
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context exerted a significant influence on the ethical development and practice of nurses. Indirect references to the ethical climates where the eight participants worked can be found throughout that study. Finally, information about the prevailing type of ethical climate in New Zealand healthcare workplaces can be extrapolated from the findings of a replication of the International Hospital Outcomes Study,17 which occurred when Finlayson et al.18 surveyed 4603 registered and enrolled nurses from 24 hospitals in New Zealand, to gauge their views on their work environments and employing organisations. A significant finding was that New Zealand nurses reported higher rates of burnout, and intention to leave (among nurses aged 30 years or younger), compared to nurses from the other countries surveyed in the original study.18
Method A qualitative descriptive approach was seen as an important starting point for examining ethical climates within the New Zealand context. This approach is appropriate when little is known about the perceptions of the population of interest.19 Furthermore, a focus group setting is especially suitable for exploring a phenomenon which consists of people’s shared perceptions about their workplace ethical climate. Unlike interviews or questionnaires, meaning can be captured through the words and interactions of focus group participants, which gives added insight into their attitudes, beliefs, experiences and feelings.20 Two focus group meetings were held. Seven registered nurses participated in the first group meeting. Four of them returned for the second meeting, which took place 2 months later. The first focus group meeting began with a general, opening question: What is the best or worst thing about working in your ward? Unexpectedly – and without exception – all participants identified issues that were relevant to the study. This led straight into the discussion that followed. Among other questions, participants were asked to identify the most common ethical issue they confronted each day in their work and to identify the most common environmental factors affecting their ethical practice. They were also asked whether they felt supported and safe raising and discussing ethical issues within their team, with their manager(s) and within the wider team, and to describe some ethically difficult situations they encountered.
Participants To preserve group homogeneity and maximise the strength of frank discussion, participation was restricted to staff (ward) nurses only – as opposed to nurse managers and nurse educators. Although nursing staff on three medical wards were canvassed, the seven study participants came from one ward, and all were internationally registered nurses. Four of the all-female group were from the Philippines, and three were from India. This is not surprising when put into context because the percentage of internationally registered nurses working on this particular ward was greater than the national figure, which in 2011 was 24% of the total New Zealand nursing workforce.21 In fact, 22 of the 28 registered nurses working in the ward were internationally registered. The longest-serving staff member participating in the study had worked in the ward for 7 years, while the newest had worked there for 1 year. During the period between the two focus group sessions, one participant resigned from the ward in order to take up a new job on another ward within the same hospital. All the participants had received formal ethics education as part of their nursing qualification, although none were familiar with the concepts of ‘nurse moral distress’ or ‘ethical climate’ prior to participating in the study.
Data analysis An inductive method of thematic data analysis was chosen for this study. Thematic analysis involves identifying, analysing and reporting themes across the data.22 A theme represents a level of ‘patterned’ 3
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response, or meaning, within the data – it captures something significant about the data in relation to the research question.22 The actual process of analysis involves reducing the data into manageable form by organising it around certain themes.23 Data analysis was guided by Braun and Clarke’s22 15-point checklist, which sets out the criteria for conducting thematic analysis (p. 96). Three main themes were identified. Each main theme was subsequently divided into two themes, which were then refined further into a number of sub-themes. Themes were labelled using the participants’ own words, or as near to their own words as possible. A key strategy for establishing validity in focus group research is ‘member checking’ of the data. At the beginning of the second focus group meeting, participants were given a written summary of the draft themes extrapolated from data gathered during the first group meeting. This enabled them to verify that the themes were an accurate representation of their thoughts and feelings. Additionally, the use of time triangulation, which determines the congruence of a phenomenon across time, was possible because of the 2-month timeframe between the two focus group sessions. Data were also searched systematically for disconfirming evidence, which is a further way of ensuring validity in qualitative research.
Ethics approval Ethics approval for this study was granted by the New Zealand Ministry of Health’s Central Regional Health and Disability Ethics Committee.
Results Chambliss24 makes two general observations regarding the nature of nurses’ ethical problems which are applicable to the findings from this study. The first is that nurses’ ethical problems are systematic – they are not isolated one-off occurrences, but are widespread and arise in predictable settings on a recurring basis. Such problems pertain to the system or organisation rather than the individual nurse. Therefore, if one nurse leaves and is replaced, the replacement is likely to encounter the same problems. The second observation is that nurses tend to face practical problems rather than individual dilemmas. These points reflect the tension that arises for nurses in their everyday work, between what should be done and what can be done – depending on whatever constraints are present. Hamric25 suggests that because nurses’ ethical problems are so firmly embedded in everyday clinical practice, they should be categorised as ‘everyday ethics’ (p. 199). Similarly, Austin26 maintains that because nurses’ ethical issues are so deeply ingrained, they may not even be recognised as ethical problems. With these points in mind, the findings from this study will be summarised. Participants’ perceptions were centred on the effects of three dominant, interrelated factors, which shape the ward’s ethical climate. These factors are staffing levels, patient throughput (turnover) and the dynamics between the nursing staff and others within the workplace. These issues are captured in the three main themes identified in the data and, at a more detailed level, by the various sub-themes that flowed from each main theme. A ‘thematic map’, depicting each main theme and its associated themes and sub-themes, is given in Figure 1 below, followed by a summary of the main findings.
Being burdened As Corley et al.5 observed elsewhere almost a decade ago, short-staffing was identified as the biggest ethical constraint. When describing their workload on the ward where the demand for medical beds is high and nurse numbers are limited, one participant commented, ‘It’s like we’re burdened’ (RN5). There are two dimensions to this burden – physical and psychological. In discussing the physical dimension of 4
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Figure 1. Thematic map: ethical climate study.
this burden, patients were described as being either ‘heavy’ or ‘light’, in terms of acuity and workload. The heaviest, sickest and, therefore, most vulnerable patients were nursed in the ward, while lighter patients were routinely boarded onto other wards to make way for new arrivals. ‘Heavy’ patients were frequently older people, often with multiple co-morbidities and invariably needing multiple medications. They relied on staff for even the most basic needs, such as feeding, toileting and, if bedridden, regular repositioning. Those who could walk often needed the help of one or more staff to do so safely. Because of the intense physical burden, nurses were overstretched and could not devote sufficient time to each patient. Nurse–patient ratios were described as a major concern by all participants, plus the lack of support staff. Night shifts were the greatest source of concern however, with nurses working on their own at night in a wing with 12 or 13 patients. Because of the ward layout, this meant being physically isolated from the other nurses on duty. As one participant commented, ‘The worst thing is doing night shift because (there are) only three nurses – only one nurse in each pod and that (means) looking after 12 patients . . . there are safety and health issues’ (RN3). In addition to being concerned about their patients, participants were also concerned for their colleagues. One participant noted about handing over from the afternoon shift to the night shift, ‘You get so relieved that the shift has ended, but you get so worried, you know. I feel bad for the night nurses . . . about what could be happening’ (RN7). Despite being told by management that the ward was not short-staffed, this was contrary to participants’ everyday experiences at the bedside. Their physical burden was compounded if anyone was sick, because of difficulties getting replacement staff through the hospital casual pool. Every participant agreed that inadequate sick leave cover remained an on-going problem. Also problematic was the lack of back up during occasions when staff had to leave the ward, for example, to accompany a patient for a procedure elsewhere within the hospital. The lack of cover added to an existing heavy workload and worsened an already precarious situation in the ward in terms of patient safety. A potential solution to the problem was volunteered by participants however, who felt that ward nurse managers could offer practical help for those on the floor, even for 10 or 20 minutes, during times when their workload peaked 5
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during the day. They emphasised that nurse managers were already aware if there was an influx of new patients, or if there was no one to cover for an absent staff member. When discussing the psychological dimension of being burdened, participants perceived their relationship with patients as being based on missed or compromised care. As one participant commented, ‘They are not getting the proper care, though we want to give quality care’ (RN6). The impact of being responsible for their patients, without any influence over the number of patients they had to care for each shift, was evident in much of the discussion. All acknowledged feelings such as anger, guilt, anxiety and withdrawing emotionally from patients, as a result of having to ration their care. These reactions, and the resignation of one participant from the ward, illustrate the cumulative effect of being burdened. This also supports the connection between negative ethical climate perceptions and nurses’ intent to turnover identified in overseas studies.27,28 It reinforces Hart’s28 comment that job dissatisfaction and turnover are likely if nurses’ primary obligation to their patients is compromised.
‘Push the bed’ The rate of patient throughput was identified as having an overwhelmingly negative impact on the ward’s ethical climate. Although the term ‘push the bed’ was used frequently by participants, the word ‘bed’ is a euphemism. That is, it is not a bed that is being pushed through the hospital system, but a human being. Someone who has been admitted to hospital for medical and nursing care and who, more often than not, requires assistance with even the most basic of activities. Most importantly, it is someone who deserves care and respect. At the heart of this theme is the dissonance created for nurses – between having to meet organisational patient flow objectives, while fulfilling their own professional and ethical objectives. Participants described the flow of patients through the ward as unrelenting. Because of the high demand for medical beds, patients are admitted or transferred to other wards at all hours of the day and night. The organisation’s policy on patient flow is based on the New Zealand Ministry of Health’s29 shorter stays in emergency department (ED) target, which aims to move patients from hospital EDs within 6 hours of their arrival. As one participant commented, ‘The big, big, bed crisis – it does affect us’ (RN5). What makes this difficult for the nursing staff is the urgency attached to patient moves within the context of the ‘burden’ of short-staffing, as discussed above. Pushing patients through the system rather than patient care was singled out as being the organisation’s main priority by one participant, who felt that patients were seen by those in management just as ‘number of beds’ (RN1). In addition to pressuring staff to move patients through the system, The Big Bed Crisis also represents a constraint for these nurses – on caring for the patients who are being moved and for the ones who remain in the ward. For example, ‘Sometimes people are waiting in the corridor and we have to rush them down and then admit another one . . . sometimes there are days like that’ (RN4). Patients are moved with seemingly little or no regard for whatever may be happening in the ward, for example, during patient handover times, and irrespective of what nursing staff or patients are doing at the time. Furthermore, the haste with which patients were moved out of the ward meant that essential things were often overlooked. These essentials include paperwork and advising family members if a patient was being moved to a different area of the hospital. That patients’ personal property goes missing in transit highlights the urgency that accompanies patient transfers. Some medical patients had multiple transfers per admission, as one participant noted, ‘They are moved SO many times (per) admission. Two days or three days – three or four times moving around’ (RN6). Pushing patients through the system also meant that basic things were often left undone, despite the nurses’ best efforts. It meant that some patients were discharged without the necessary work being completed by the nursing staff. Moral distress was evident as a result of this situation – indeed, as one participant pointed out, 6
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It’s very distressing to us . . . they discharge the patient, even though we are not ready as nurses to discharge the patient... we have left the paperwork undone, the personal cares undone. And all other bits and pieces like informing the family. (RN5)
This reveals the difficulty of being responsible for patients, but not having the corresponding power to influence what happens to them. There was consensus among the group that there was never enough time to do everything that needs to be done. In addition to pushing patients, participants described being pushed themselves – to meet organisational goals regarding patient flow on the one hand, while trying to fulfil their ethical obligations towards their patients on the other. They are also pushed to send patients to other wards, or to discharge them, irrespective of whether they consider those patients are ready to be discharged. As one participant commented, ‘Even though we feel for the patient, we don’t have a choice’ (RN5). Overall, when describing the conflicting demands and obligations placed on the nurses as a result of being pushed to move patients quickly through the system, participants agreed that organisational objectives regarding patient flow were important, despite the load this put on the nursing staff. They spoke of their dual obligation – towards the patients who are already in the ward, as well as towards the patients who were coming in. As one participant pointed out, ‘We’re not actually refusing the patient that’s coming in . . . we need to accommodate them as well’ (RN5). The difficulty here is that the dual obligation has to be fulfilled within the context of factors described above, such as short-staffing and an existing heavy patient workload.
Us and them The third dominant factor shaping the ward ethical climate was the relationship between ward staff nurses and others in their workplace. The majority of participants identified their nursing team as the best thing about working in the ward. They drew strength from the support of their colleagues within the nursing team. When asked who they turned to when ethical issues arose in the ward, one participant stated that she was comfortable discussing things only among the nursing team, because all the nurses faced the same issues and felt the same. That these nurses relied on each other when dealing with ethical problems supports findings from a Canadian study of nurses and nurse leaders.30 Participants explained that the nurses acknowledged the difficult times among themselves – within the nursing team. There was no experience of, or expectation, that management would acknowledge any especially difficult situations the nurses had to cope with, ‘We comfort each other . . . we can cry on each other – not to them’ (RN1). Significantly, participants spoke of the mutually respectful relationship that existed between the nurses and their medical colleagues. The consultants, in particular, were held in high regard by the nursing staff because of their attitudes towards them. ‘They value the nurses’ input’ (RN1). This situation contrasts markedly with instances of nurse–doctor conflict described in overseas studies on ethical climate and nurse moral distress.6,31,32 It also contrasts with participants’ perceptions of the relationship between nurses and management (which encompasses ward managers, hospital duty nurse managers and the wider organisation). For example, participants expressed disappointment at not getting a permanent healthcare assistant for night shifts, which had been promised by the Director of Nursing. Because this was attributed to the budget, there was a general perception that the budget took priority over safety – which reflects a conflict between organisational and nurses’ values. A general sense of disappointment emerged too, when participants described the response of some managers when nurses voiced their concerns regarding patient safety and staffing levels. Typically, the consequences of an inherently systemic problem were turned around and instead attributed to individual failings (on the part of whoever raised the issue). As one participant noted, ‘One of the staff members . . . got told by the manager . . . that . . . oh, maybe you have issues with your time management . . . something like that’ (RN5). 7
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Participants emphasised the powerful effect of negative attitudes towards staff, from those who are in positions of power. For example, when concerns were raised about staffing levels, ‘Sometimes we get feedback, you know, you’re not a team player . . . you know things like that. It goes against us’ (RN5). This stance effectively shuts down any dialogue between staff and ward management on an issue that is both crucial to patient safety and pivotal to nurses being able to fulfil their ethical responsibilities. Newton et al.33 found that when nurses are not supported in practice and their voices are silenced, they are unable to enact their moral agency. They argue that a ‘noisy’ ethical climate – where nurses’ voices are heard – is essential within a positive ethical practice environment.33 Being silenced is, of course, a precursor to moral distress.
Discussion While it is useful to know that ethical climates are ubiquitous, that different types exist and that some are more favourable for nursing than others, the greatest significance of this concept for nurses is its connection with moral distress. Moral distress does not occur in a vacuum; it is always the product of a negative ethical climate. Hence, the growing number of studies4–8 that have linked nurse workplace ethical climates to the experience and incidence of moral distress, and this research adds to the list. The notion of nurses being responsible, but without any corresponding power or influence, was a recurring element in the research. In ethical terms, staff nurses are responsible for (and answerable to) others in everything they do. Yet it was clear from discussion that participants’ ability to influence how things are done is constrained by an array of contextual factors. These factors are all underpinned by one common thread – powerlessness. Powerlessness has been described as a central cause and key element in the experience of moral distress.25 This thread links all the themes identified in this study together. Short-staffing was identified as the most pressing environmental factor that constrained participants from fulfilling their ethical obligations. This finding is consistent with the results of the first New Zealand study of nurse moral distress,2 where unsafe staffing levels were reported as causing the greatest intensity of moral distress among nurses who participated in that study. Studies carried out in the United States, Canada and Sweden5,8,34–36 have also found that perceptions of unsafe staffing were associated with the highest frequency and intensity of moral distress and identified as the most stressful ethical issue confronting nurses who participated in those studies. Findings from this study indicate that the capacity of nurses to cope with their workload is tested on a daily basis. Being chronically understaffed appears to have become the baseline for these nurses – particularly on night shifts. Participants’ comments in both meetings and the resignation of one participant from the ward reveal the intensity of the nurses’ moral distress as a result of this situation. That participant described being ‘pushed to the edge’ as a result of the stress that had accumulated during her time in the ward. This fits the pattern of ‘moral residue’ described by Webster and Baylis,37 who used the term to describe the lingering and powerful thoughts and feelings that remain with the individual, following a morally distressing situation. This study found that nursing staff were painted into a corner in ethical terms. Unable to enact their ethical values as a result of unsafe staffing levels and the sheer volume of patient throughput, they also had little opportunity to air their concerns in the hope of addressing these issues. Moral distress was evident in many of the situations described by participants – the result of having to continually compromise in an uncompromising environment. In their systematic review of qualitative evidence on nurse moral distress, Huffman and Rittenmeyer38 point out that there is an organisational culpability associated with the experience of nurse moral distress in hospital environments – irrespective of the specific geographical or cultural context. These researchers 8
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note that moral distress is felt most intensely by nurses when they are obliged to advocate for their patients while coping with institutional constraints on their ethical behaviour. They cite unrealistic and unsafe staffing patterns as being common in nurses’ narratives of situations that give rise to moral distress (p. 97).38 In this instance, the negative effects of short-staffing are magnified by the impact of high patient throughput in the ward. Significantly, this particular issue is a departure from negative climate antecedents reported elsewhere. Although ethical conflict with organisational policies has been recognised as a source of moral distress for nurses,5,39,40 the impact of high patient throughput does not appear to have been singled out as a contributing factor. Instead, policies relating to budget and controlling costs tend to be the focus of attention.5,41,42 Findings from this study illustrate that the participants all perceived the organisation’s main priority to be patient throughput, rather than the quality of patient care. Patients are not just numbers however, as one participant rightly pointed out. Rather, each person has their own unique needs and complexities, which must be taken into account when patients (and nurses) are converted into numbers for business planning purposes. The reason that the high volume of patient throughput has such a negative impact on the nurses’ ability to care for their patients is reflected by Park et al.43 who argue that patient throughput should be included in the equation when nurse staffing levels are determined because of the additional demands it places on nurses’ time. In situations where turnover is high, the nursing workload increases because a more concentrated degree of care is given to a larger number of patients than the total number of beds in the ward indicates.43 Furthermore, this increased workload must be carried out within a shorter timeframe, in order to meet the needs of the increasing number of patients moving through the system.43 As participants in this study explained, although they are told by management that the ward is not short-staffed, their actual bedside experiences strongly indicate otherwise. A significant association has been established between increased patient mortality, high patient turnover and ‘below target’ nurse staffing levels.44 Conversely, higher levels of registered nurse staffing have been linked empirically to lower rates of failure to rescue.43 ‘Failure to Rescue’ refers to patient mortality resulting from preventable complications, including decubitus ulcers, deep vein thrombosis, falls, urinary tract infections, gastrointestinal bleeding and central nervous system complications.45 Mortality is, of course, the extreme consequence of these complications. Finally, of note in the findings from this study was the call from participants for managers to exercise leadership by advocating on behalf of the nursing staff (and their patients). The key role of leaders in facilitating supportive, positive ethical climates has been emphasised in a number of studies.30,46–49 However, a lack of leadership was perceived as a ‘pervasive problem’ in a recent Canadian survey of moral distress and ethical climate.32 In this study, participants’ comments regarding the attitudes and behaviour of some managers towards nursing staff, when staff voice their concerns over safety for example, could suggest that those managers too could be experiencing moral distress.
Limitations This study is limited by its small sample size. Another potential limitation is that all participants were internationally registered nurses, because it could be argued that the added perspective of locally registered nurses may have enhanced the findings. Additionally, the findings are limited to this specific group of participants.
Implications The findings from this study have implications for nurses, their employers and for the nursing profession in New Zealand as a whole. There is an urgent need to raise awareness of the twin concepts of ethical climate 9
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and moral distress among members of the New Zealand nursing workforce at all levels. For ward nurses, it is vital that they recognise and understand why those situations where their moral agency is thwarted have such a resounding and haunting effect on them. For nurse leaders, their key role in promoting a positive ethical climate cannot be overstated. Additionally, the findings from this study should be of particular concern to healthcare managers and policymakers, both at organisational and national levels. These findings illustrate the unintended, but nonetheless significant, downstream consequences at ward (or micro) level of policies that originate at the socio-political (or macro-) level. The detrimental impact on ward nurses’ ethical practice of patient flow initiatives and budgetary policies should not be underestimated. That nurses are experiencing moral distress as a result of such policies indicates that patient care is suffering.
Conclusion To conclude, participants perceived their ward ethical climate in generally unfavourable terms. Although peers within the nursing team were perceived as being extremely supportive and nurses had a good rapport with their medical colleagues, three dominant, negative factors had a synergistic effect in shaping the ward’s ethical climate. These interrelated factors were inadequate staffing, high patient throughput and the attitude of some managers towards nursing staff when concerns were raised about staffing and patient safety. While the findings from this study with regard to staffing levels and the power dynamics between nurses and managers support those from ethical climate research carried out overseas, of note is the impact of patient turnover policy on local nurses’ ethical practice. This issue has not been singled out as having a detrimental influence on ethical climates elsewhere. Compromised patient care was identified as the most prevalent ethical issue nurses confronted in their daily practice, while short-staffing was the most common factor affecting nurses’ ethical practice. Clearly, these nurses do not have a choice in this situation; their hands are tied as a result of constraints within this particular ethical climate. Here, the negative influences far outweigh the positive elements. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. New Zealand Nurses Organisation. Code of ethics. Wellington, New Zealand: NZNO, 2010, http://www.nzno. org.nz (2010, accessed November 2012). 2. Woods M, Rodgers V, Towers A, et al. Researching moral distress among New Zealand nurses: a national survey. Nurs Ethics. Epub ahead of print 7 August 2014. DOI: 10.1177/0969733014542679. 3. Olson LL. Hospital nurses’ perceptions of the ethical climate of their work setting. Image J Nurs Sch 1998; 30(4): 345–349. 4. Ulrich C, O’Donnell P, Taylor C, et al. Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Soc Sci Med 2007; 65(8): 1708–1719. 5. Corley MC, Minick P, Elswick RK, et al. Nurse moral distress and ethical work environment. Nurs Ethics 2005; 12(4): 381–390. 6. Hamric AB and Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med 2007; 35(2): 422–429. 10
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7. Lu¨tzen K, Blom T, Ewalds-Kvist B, et al. Moral stress, moral climate and moral sensitivity among psychiatric professionals. Nurs Ethics 2010; 17(2): 213–224. 8. Pauly B, Varcoe C, Storch J, et al. Registered nurses’ perceptions of moral distress and ethical climate. Nurs Ethics 2009; 16(5): 561–573. 9. Jameton A. Nursing practice: the ethical issues. Englewood Cliffs, NJ: Prentice Hall, 1984. 10. Wilkinson JM. Moral distress in nursing practice: experience and effect. Nurs Forum 1987/88; 23(1): 16–29. 11. Meltzer LS and Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care 2004; 13(3): 202–208. 12. McCarthy J and Deady R. Moral distress reconsidered. Nurs Ethics 2008; 15(2): 254–263. 13. Chalmers L. Nurse managers’ ethical conflicts with their health care organisations: a New Zealand perspective. Unpublished Master’s Thesis, Massey University, Palmerston North, New Zealand, http://mro.massey.ac.nz/bitstream/handle/10179/862/02whole.pdf?sequence¼1 (2008, accessed November 2012). 14. Butters K. A qualitative study of the ethical practice of newly graduated nurses working in mental health. Unpublished Master’s Thesis, Massey University, Palmerston North, New Zealand, http://mro.massey.ac.nz/bitstream/ handle/10179/860/02whole.pdf?sequence¼1 (2008, accessed November 2012). 15. Vallance E. ‘Navigating through’: a grounded theory of the development of ethical practice in undergraduate nurses. Unpublished Master’s Thesis, Massey University, Palmerston North, New Zealand, 2003. 16. Woods M. Maintaining a nursing ethic: a grounded theory of the moral practice of experienced nurses. Unpublished Master’s Thesis, Massey University, Palmerston North, New Zealand, 1997. 17. Aiken LH, Clarke SP, Sloane DM, et al. Nurses’ reports on hospital care in five countries. Health Aff 2001; 20: 43–53. 18. Finlayson M, Aiken L and Nakarada-Kordic I. New Zealand nurses’ reports on hospital care: an international comparison. Nurs Prax N Z 2007; 23(1): 17–28. 19. Polit DF and Beck CT. Nursing research: generating and assessing evidence for nursing practice. 8th ed. Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins, 2008. 20. Litosseliti L. Using focus groups in research. London: Continuum, 2003. 21. Nursing Council of New Zealand. The New Zealand nursing workforce: a profile of nurse practitioners, registered nurses, and enrolled nurses 2011. Wellington, New Zealand: NCNZ, www.nursingcouncil.org.nz (2012, accessed September 2012). 22. Braun V and Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101. 23. Tolich M and Davidson C. Getting started: an introduction to research methods. Auckland, New Zealand: Pearson, 2011. 24. Chambliss DF. Beyond caring: hospitals, nurses, and the social organisation of ethics. Chicago, IL: University of Chicago Press, 1996. 25. Hamric AB. Moral distress in everyday ethics. Nurs Outlook 2000; 48: 199–201. 26. Austin W. The ethics of everyday practice: healthcare environments as moral communities. Adv Nurs Sci 2007; 30(1): 81–88. 27. Fogel KM. The relationships of moral distress, ethical climate, and intent to turnover among critical care nurses. Unpublished Doctoral Dissertation, Loyola University, Chicago, IL, http://books.google.co.nz/books? isbn¼3845404922 (2007, accessed August 2012). 28. Hart SE. Hospital ethical climates and registered nurses’ turnover intentions. J Nurs Scholarsh 2005; 37(2): 173–177. 29. Ministry of Health. Targeting emergencies: shorter stays in emergency departments. Wellington, New Zealand: Ministry of Health, http://www.health.govt.nz/new-zealand-health-system/health-targets/2012-13-health-targets/ health-targets-2012-13-shorter-stays-emergency-departments (2011, accessed August 2012). 30. Storch JL, Rodney P, Pauly B, et al. Listening to nurses’ moral voices: building a quality health care environment. Can J Nurs Leadersh 2002; 15(4): 7–16. 11
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31. Gutierrez KM. Critical care nurses’ perceptions of and responses to moral distress. Dimens Crit Care Nurs 2005; 24(5): 229–241. 32. Varcoe C, Pauly B, Storch J, et al. Nurses’ perceptions of and responses to morally distressing situations. Nurs Ethics 2012; 19(4): 488–500. 33. Newton L, Storch J, Makaroff KS, et al. ‘Stop the noise!’ From voice to silence. Nurs Leadersh 2012; 25(1): 90–104. 34. Sile´n M, Tang PF, Wadensten B, et al. Workplace distress and ethical dilemmas in neuroscience nursing. J Neurosci Nurs 2008; 40(4): 222–231. 35. Ulrich C, Taylor C, Soeken K, et al. Everyday ethics: ethical issues and stress in nursing practice. J Adv Nurs 2010; 66(11): 2510–2519. 36. Zuzelo P. Exploring the moral distress of registered nurses. Nurs Ethics 2007; 14(3): 344–359. 37. Webster GC and Baylis FE. Moral residue. In: Rubin SB and Zoloth L (eds) Margin of error – the ethics of mistakes in the practice of medicine. Hagerstown, MD: University Publishing Group, 2000, pp. 217–229. 38. Huffman DM and Rittenmeyer L. How professional nurses working in hospital environments experience moral distress: a systematic review. Crit Care Nurs Clin North Am 2012; 24: 91–100. 39. Gaudine A, LeFort SM, Lamb M, et al. Ethical conflicts with hospitals: the perspective of nurses and physicians. Nurs Ethics 2011; 18(6): 756–766. 40. Redman BK and Fry ST. Nurses’ ethical conflicts: what is really known about them? Nurs Ethics 2000; 7(4): 360–366. 41. Joseph J and Deshpande SP. The impact of ethical climate on job satisfaction of nurses. Health Care Manage Rev 1997; 22(1): 76–81. 42. Ka¨lvemark S, Ho¨glund AT, Hansson MG, et al. Living with conflicts – ethical dilemmas and moral distress in the health care system. Soc Sci Med 2003; 58: 1075–1084. 43. Park SH, Blegen MA, Spetz J, et al. Patient turnover and the relationship between nurse staffing and patient outcomes. Res Nurs Health 2012; 35: 277–288. 44. Needleman J, Buerhaus P, Pankratz S, et al. Nurse staffing and inpatient hospital mortality. N Engl J M 2011; 364(11): 1037–1045. 45. Walker L and Clendon J. Failure to rescue: a New Zealand perspective 2012 – NZNO research literature review. Wellington, New Zealand: NZNO, http://www.nzno.org.nz/SearchResults/tabid/131/Default.aspx?search¼failureþ toþrescue&;sb-inst¼0dnnavtSearch&sb-logid¼46808-iewdkriak8woqu6o (2012, accessed December 2012). 46. Filipova AA. Licensed nurses’ perceptions of ethical climates in skilled nursing facilities. Nurs Ethics 2009; 16(5): 574–588. 47. McDaniel C. Ethical environment: reports of practicing nurses. Nurs Clin North Am 1998; 33(2): 363–372. 48. Shirey MR, Ebright PR and McDaniel AM. Sleepless in America – nurse managers cope with stress and complexity. J Nurs Adm 2008; 38(3): 125–131. 49. Wall S and Austin W. The influence of teams, supervisors and organisations on healthcare practitioners’ abilities to practise ethically. Nurs Leadersh 2008; 21(4): 85–99.
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A study of nurses’ ethical climate perceptions: Compromising in an uncompromising environment
Nursing Ethics 1–12 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733014564101 nej.sagepub.com
Anne Humphries and Martin Woods Massey University, New Zealand
Abstract Background: Acting ethically, in accordance with professional and personal moral values, lies at the heart of nursing practice. However, contextual factors, or obstacles within the work environment, can constrain nurses in their ethical practice – hence the importance of the workplace ethical climate. Interest in nurse workplace ethical climates has snowballed in recent years because the ethical climate has emerged as a key variable in the experience of nurse moral distress. Significantly, this study appears to be the first of its kind carried out in New Zealand. Aim/objective: The purpose of this study was to explore and describe how registered nurses working on a medical ward in a New Zealand hospital perceive their workplace ethical climate. Research design/participants/context: This was a small, qualitative descriptive study. Seven registered nurses were interviewed in two focus group meetings. An inductive method of thematic data analysis was used for this research. Ethical considerations: Ethics approval for this study was granted by the New Zealand Ministry of Health’s Central Regional Health and Disability Ethics Committee on 14 June 2012. Findings: The themes identified in the data centred on three dominant elements that – together – shaped the prevailing ethical climate: staffing levels, patient throughput and the attitude of some managers towards nursing staff. Discussion: While findings from this study regarding staffing levels and the power dynamics between nurses and managers support those from other ethical climate studies, of note is the impact of patient throughput on local nurses’ ethical practice. This issue has not been singled out as having a detrimental influence on ethical climates elsewhere. Conclusion: Moral distress is inevitable in an ethical climate where the organisation’s main priorities are perceived by nursing staff to be budget and patient throughput, rather than patient safety and care. Keywords Ethical climate, medical nursing, moral distress, nursing ethics, thematic analysis
Corresponding author: Anne Humphries. Email: [email protected]
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Introduction Although unseen, the ethical climate of any workplace exerts a powerful and pervasive influence on the ethical behaviour of the people who work there. It is particularly significant for nurses because the nursing profession was founded on ‘the moral premise of caring, and the belief that nurses have a commitment to do good’ (p. 9).1 Nursing is an inherently moral endeavour. Consequently, the prevailing workplace ethical climate has a major and far-reaching effect on nurses and their patients, because of its pivotal role in either facilitating or constraining nurses’ ethical practice. The purpose of this small study was to explore and describe how registered nurses working on a medical ward in a New Zealand hospital perceive their workplace ethical climate. The hospital provides a range of specialist secondary and regional services to a large city- and regional-based population. The medical ward has 37 beds, distributed among three discrete wings. Although research into nurse moral distress within the New Zealand context is emerging,2 it appears that the ethical climates of nurse workplaces in this country have not been explored prior to this study. The dual objective for doing this study was to generate interest in this important phenomenon within the local setting, while adding to the small – but growing – body of nursing ethics literature in New Zealand.
Background and significance of the study In the nursing literature, ethical climate refers to the shared perceptions of organisational practices surrounding ethical decision-making and reflection, including issues of power, trust and human interaction.3,4 Interest in this concept has grown considerably in recent years because the workplace ethical climate has emerged as a key factor in the experience of nurse moral distress.4–8 Negative climate antecedents are therefore of most concern because these can precipitate moral distress. Moral distress was originally conceptualised by Jameton,9 who described it as occurring when ‘one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (p. 6). Wilkinson10 later expanded upon this definition by noting the ‘psychological disequilibrium and negative feeling state’ (p. 16) that follows when an individual makes a moral decision, but cannot follow it through, due to situational constraints. It is associated with various physical and psychological symptoms,10 including emotional exhaustion, which is linked to burnout.11 More recently, moral distress was defined as an umbrella or cluster concept, capturing the experiences of individuals who are morally constrained.12 This definition allows for the fact that moral constraints can be specific to the individual (internal), or specific to the particular workplace (external). In the New Zealand context, inferences concerning ethical climates in healthcare workplaces can be drawn particularly from emerging New Zealand research on moral distress. For instance, preliminary findings from the first national study of nurse moral distress in New Zealand2 indicate that almost half of the 412 hospital-based respondents had considered leaving their current job as a result of moral distress in the workplace. Other local studies in nursing ethics refer indirectly to the impact of workplace ethical climates. One, concerning nurse managers’ ethical conflict with their employing organisations,13 refers to conflicts being caused by the ‘duality of professional and organisation values that their roles encompass’ (p. 114). Another local study, concerning the ethical practice of eight newly graduated nurses working in mental health,14 refers to factors affecting participants’ ethical practice, such as ‘disempowering and difficult relationship problems’ (p. 96). In another study, Vallance15 examined the undergraduate ethics preparation for practice of nine new graduate nurses. In making the transition from ‘ideal’ to ‘real’ in ethical terms, participants in that study had to refocus their own ‘ethical perspective’ and, in doing so, sacrificed their ‘ethical ideals’ as a result of contextual constraints within the workplaces where they were sent on placement. A further study by Woods16 explored the moral decision-making of experienced nurses and found that the healthcare 2
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context exerted a significant influence on the ethical development and practice of nurses. Indirect references to the ethical climates where the eight participants worked can be found throughout that study. Finally, information about the prevailing type of ethical climate in New Zealand healthcare workplaces can be extrapolated from the findings of a replication of the International Hospital Outcomes Study,17 which occurred when Finlayson et al.18 surveyed 4603 registered and enrolled nurses from 24 hospitals in New Zealand, to gauge their views on their work environments and employing organisations. A significant finding was that New Zealand nurses reported higher rates of burnout, and intention to leave (among nurses aged 30 years or younger), compared to nurses from the other countries surveyed in the original study.18
Method A qualitative descriptive approach was seen as an important starting point for examining ethical climates within the New Zealand context. This approach is appropriate when little is known about the perceptions of the population of interest.19 Furthermore, a focus group setting is especially suitable for exploring a phenomenon which consists of people’s shared perceptions about their workplace ethical climate. Unlike interviews or questionnaires, meaning can be captured through the words and interactions of focus group participants, which gives added insight into their attitudes, beliefs, experiences and feelings.20 Two focus group meetings were held. Seven registered nurses participated in the first group meeting. Four of them returned for the second meeting, which took place 2 months later. The first focus group meeting began with a general, opening question: What is the best or worst thing about working in your ward? Unexpectedly – and without exception – all participants identified issues that were relevant to the study. This led straight into the discussion that followed. Among other questions, participants were asked to identify the most common ethical issue they confronted each day in their work and to identify the most common environmental factors affecting their ethical practice. They were also asked whether they felt supported and safe raising and discussing ethical issues within their team, with their manager(s) and within the wider team, and to describe some ethically difficult situations they encountered.
Participants To preserve group homogeneity and maximise the strength of frank discussion, participation was restricted to staff (ward) nurses only – as opposed to nurse managers and nurse educators. Although nursing staff on three medical wards were canvassed, the seven study participants came from one ward, and all were internationally registered nurses. Four of the all-female group were from the Philippines, and three were from India. This is not surprising when put into context because the percentage of internationally registered nurses working on this particular ward was greater than the national figure, which in 2011 was 24% of the total New Zealand nursing workforce.21 In fact, 22 of the 28 registered nurses working in the ward were internationally registered. The longest-serving staff member participating in the study had worked in the ward for 7 years, while the newest had worked there for 1 year. During the period between the two focus group sessions, one participant resigned from the ward in order to take up a new job on another ward within the same hospital. All the participants had received formal ethics education as part of their nursing qualification, although none were familiar with the concepts of ‘nurse moral distress’ or ‘ethical climate’ prior to participating in the study.
Data analysis An inductive method of thematic data analysis was chosen for this study. Thematic analysis involves identifying, analysing and reporting themes across the data.22 A theme represents a level of ‘patterned’ 3
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response, or meaning, within the data – it captures something significant about the data in relation to the research question.22 The actual process of analysis involves reducing the data into manageable form by organising it around certain themes.23 Data analysis was guided by Braun and Clarke’s22 15-point checklist, which sets out the criteria for conducting thematic analysis (p. 96). Three main themes were identified. Each main theme was subsequently divided into two themes, which were then refined further into a number of sub-themes. Themes were labelled using the participants’ own words, or as near to their own words as possible. A key strategy for establishing validity in focus group research is ‘member checking’ of the data. At the beginning of the second focus group meeting, participants were given a written summary of the draft themes extrapolated from data gathered during the first group meeting. This enabled them to verify that the themes were an accurate representation of their thoughts and feelings. Additionally, the use of time triangulation, which determines the congruence of a phenomenon across time, was possible because of the 2-month timeframe between the two focus group sessions. Data were also searched systematically for disconfirming evidence, which is a further way of ensuring validity in qualitative research.
Ethics approval Ethics approval for this study was granted by the New Zealand Ministry of Health’s Central Regional Health and Disability Ethics Committee.
Results Chambliss24 makes two general observations regarding the nature of nurses’ ethical problems which are applicable to the findings from this study. The first is that nurses’ ethical problems are systematic – they are not isolated one-off occurrences, but are widespread and arise in predictable settings on a recurring basis. Such problems pertain to the system or organisation rather than the individual nurse. Therefore, if one nurse leaves and is replaced, the replacement is likely to encounter the same problems. The second observation is that nurses tend to face practical problems rather than individual dilemmas. These points reflect the tension that arises for nurses in their everyday work, between what should be done and what can be done – depending on whatever constraints are present. Hamric25 suggests that because nurses’ ethical problems are so firmly embedded in everyday clinical practice, they should be categorised as ‘everyday ethics’ (p. 199). Similarly, Austin26 maintains that because nurses’ ethical issues are so deeply ingrained, they may not even be recognised as ethical problems. With these points in mind, the findings from this study will be summarised. Participants’ perceptions were centred on the effects of three dominant, interrelated factors, which shape the ward’s ethical climate. These factors are staffing levels, patient throughput (turnover) and the dynamics between the nursing staff and others within the workplace. These issues are captured in the three main themes identified in the data and, at a more detailed level, by the various sub-themes that flowed from each main theme. A ‘thematic map’, depicting each main theme and its associated themes and sub-themes, is given in Figure 1 below, followed by a summary of the main findings.
Being burdened As Corley et al.5 observed elsewhere almost a decade ago, short-staffing was identified as the biggest ethical constraint. When describing their workload on the ward where the demand for medical beds is high and nurse numbers are limited, one participant commented, ‘It’s like we’re burdened’ (RN5). There are two dimensions to this burden – physical and psychological. In discussing the physical dimension of 4
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Figure 1. Thematic map: ethical climate study.
this burden, patients were described as being either ‘heavy’ or ‘light’, in terms of acuity and workload. The heaviest, sickest and, therefore, most vulnerable patients were nursed in the ward, while lighter patients were routinely boarded onto other wards to make way for new arrivals. ‘Heavy’ patients were frequently older people, often with multiple co-morbidities and invariably needing multiple medications. They relied on staff for even the most basic needs, such as feeding, toileting and, if bedridden, regular repositioning. Those who could walk often needed the help of one or more staff to do so safely. Because of the intense physical burden, nurses were overstretched and could not devote sufficient time to each patient. Nurse–patient ratios were described as a major concern by all participants, plus the lack of support staff. Night shifts were the greatest source of concern however, with nurses working on their own at night in a wing with 12 or 13 patients. Because of the ward layout, this meant being physically isolated from the other nurses on duty. As one participant commented, ‘The worst thing is doing night shift because (there are) only three nurses – only one nurse in each pod and that (means) looking after 12 patients . . . there are safety and health issues’ (RN3). In addition to being concerned about their patients, participants were also concerned for their colleagues. One participant noted about handing over from the afternoon shift to the night shift, ‘You get so relieved that the shift has ended, but you get so worried, you know. I feel bad for the night nurses . . . about what could be happening’ (RN7). Despite being told by management that the ward was not short-staffed, this was contrary to participants’ everyday experiences at the bedside. Their physical burden was compounded if anyone was sick, because of difficulties getting replacement staff through the hospital casual pool. Every participant agreed that inadequate sick leave cover remained an on-going problem. Also problematic was the lack of back up during occasions when staff had to leave the ward, for example, to accompany a patient for a procedure elsewhere within the hospital. The lack of cover added to an existing heavy workload and worsened an already precarious situation in the ward in terms of patient safety. A potential solution to the problem was volunteered by participants however, who felt that ward nurse managers could offer practical help for those on the floor, even for 10 or 20 minutes, during times when their workload peaked 5
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during the day. They emphasised that nurse managers were already aware if there was an influx of new patients, or if there was no one to cover for an absent staff member. When discussing the psychological dimension of being burdened, participants perceived their relationship with patients as being based on missed or compromised care. As one participant commented, ‘They are not getting the proper care, though we want to give quality care’ (RN6). The impact of being responsible for their patients, without any influence over the number of patients they had to care for each shift, was evident in much of the discussion. All acknowledged feelings such as anger, guilt, anxiety and withdrawing emotionally from patients, as a result of having to ration their care. These reactions, and the resignation of one participant from the ward, illustrate the cumulative effect of being burdened. This also supports the connection between negative ethical climate perceptions and nurses’ intent to turnover identified in overseas studies.27,28 It reinforces Hart’s28 comment that job dissatisfaction and turnover are likely if nurses’ primary obligation to their patients is compromised.
‘Push the bed’ The rate of patient throughput was identified as having an overwhelmingly negative impact on the ward’s ethical climate. Although the term ‘push the bed’ was used frequently by participants, the word ‘bed’ is a euphemism. That is, it is not a bed that is being pushed through the hospital system, but a human being. Someone who has been admitted to hospital for medical and nursing care and who, more often than not, requires assistance with even the most basic of activities. Most importantly, it is someone who deserves care and respect. At the heart of this theme is the dissonance created for nurses – between having to meet organisational patient flow objectives, while fulfilling their own professional and ethical objectives. Participants described the flow of patients through the ward as unrelenting. Because of the high demand for medical beds, patients are admitted or transferred to other wards at all hours of the day and night. The organisation’s policy on patient flow is based on the New Zealand Ministry of Health’s29 shorter stays in emergency department (ED) target, which aims to move patients from hospital EDs within 6 hours of their arrival. As one participant commented, ‘The big, big, bed crisis – it does affect us’ (RN5). What makes this difficult for the nursing staff is the urgency attached to patient moves within the context of the ‘burden’ of short-staffing, as discussed above. Pushing patients through the system rather than patient care was singled out as being the organisation’s main priority by one participant, who felt that patients were seen by those in management just as ‘number of beds’ (RN1). In addition to pressuring staff to move patients through the system, The Big Bed Crisis also represents a constraint for these nurses – on caring for the patients who are being moved and for the ones who remain in the ward. For example, ‘Sometimes people are waiting in the corridor and we have to rush them down and then admit another one . . . sometimes there are days like that’ (RN4). Patients are moved with seemingly little or no regard for whatever may be happening in the ward, for example, during patient handover times, and irrespective of what nursing staff or patients are doing at the time. Furthermore, the haste with which patients were moved out of the ward meant that essential things were often overlooked. These essentials include paperwork and advising family members if a patient was being moved to a different area of the hospital. That patients’ personal property goes missing in transit highlights the urgency that accompanies patient transfers. Some medical patients had multiple transfers per admission, as one participant noted, ‘They are moved SO many times (per) admission. Two days or three days – three or four times moving around’ (RN6). Pushing patients through the system also meant that basic things were often left undone, despite the nurses’ best efforts. It meant that some patients were discharged without the necessary work being completed by the nursing staff. Moral distress was evident as a result of this situation – indeed, as one participant pointed out, 6
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It’s very distressing to us . . . they discharge the patient, even though we are not ready as nurses to discharge the patient... we have left the paperwork undone, the personal cares undone. And all other bits and pieces like informing the family. (RN5)
This reveals the difficulty of being responsible for patients, but not having the corresponding power to influence what happens to them. There was consensus among the group that there was never enough time to do everything that needs to be done. In addition to pushing patients, participants described being pushed themselves – to meet organisational goals regarding patient flow on the one hand, while trying to fulfil their ethical obligations towards their patients on the other. They are also pushed to send patients to other wards, or to discharge them, irrespective of whether they consider those patients are ready to be discharged. As one participant commented, ‘Even though we feel for the patient, we don’t have a choice’ (RN5). Overall, when describing the conflicting demands and obligations placed on the nurses as a result of being pushed to move patients quickly through the system, participants agreed that organisational objectives regarding patient flow were important, despite the load this put on the nursing staff. They spoke of their dual obligation – towards the patients who are already in the ward, as well as towards the patients who were coming in. As one participant pointed out, ‘We’re not actually refusing the patient that’s coming in . . . we need to accommodate them as well’ (RN5). The difficulty here is that the dual obligation has to be fulfilled within the context of factors described above, such as short-staffing and an existing heavy patient workload.
Us and them The third dominant factor shaping the ward ethical climate was the relationship between ward staff nurses and others in their workplace. The majority of participants identified their nursing team as the best thing about working in the ward. They drew strength from the support of their colleagues within the nursing team. When asked who they turned to when ethical issues arose in the ward, one participant stated that she was comfortable discussing things only among the nursing team, because all the nurses faced the same issues and felt the same. That these nurses relied on each other when dealing with ethical problems supports findings from a Canadian study of nurses and nurse leaders.30 Participants explained that the nurses acknowledged the difficult times among themselves – within the nursing team. There was no experience of, or expectation, that management would acknowledge any especially difficult situations the nurses had to cope with, ‘We comfort each other . . . we can cry on each other – not to them’ (RN1). Significantly, participants spoke of the mutually respectful relationship that existed between the nurses and their medical colleagues. The consultants, in particular, were held in high regard by the nursing staff because of their attitudes towards them. ‘They value the nurses’ input’ (RN1). This situation contrasts markedly with instances of nurse–doctor conflict described in overseas studies on ethical climate and nurse moral distress.6,31,32 It also contrasts with participants’ perceptions of the relationship between nurses and management (which encompasses ward managers, hospital duty nurse managers and the wider organisation). For example, participants expressed disappointment at not getting a permanent healthcare assistant for night shifts, which had been promised by the Director of Nursing. Because this was attributed to the budget, there was a general perception that the budget took priority over safety – which reflects a conflict between organisational and nurses’ values. A general sense of disappointment emerged too, when participants described the response of some managers when nurses voiced their concerns regarding patient safety and staffing levels. Typically, the consequences of an inherently systemic problem were turned around and instead attributed to individual failings (on the part of whoever raised the issue). As one participant noted, ‘One of the staff members . . . got told by the manager . . . that . . . oh, maybe you have issues with your time management . . . something like that’ (RN5). 7
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Participants emphasised the powerful effect of negative attitudes towards staff, from those who are in positions of power. For example, when concerns were raised about staffing levels, ‘Sometimes we get feedback, you know, you’re not a team player . . . you know things like that. It goes against us’ (RN5). This stance effectively shuts down any dialogue between staff and ward management on an issue that is both crucial to patient safety and pivotal to nurses being able to fulfil their ethical responsibilities. Newton et al.33 found that when nurses are not supported in practice and their voices are silenced, they are unable to enact their moral agency. They argue that a ‘noisy’ ethical climate – where nurses’ voices are heard – is essential within a positive ethical practice environment.33 Being silenced is, of course, a precursor to moral distress.
Discussion While it is useful to know that ethical climates are ubiquitous, that different types exist and that some are more favourable for nursing than others, the greatest significance of this concept for nurses is its connection with moral distress. Moral distress does not occur in a vacuum; it is always the product of a negative ethical climate. Hence, the growing number of studies4–8 that have linked nurse workplace ethical climates to the experience and incidence of moral distress, and this research adds to the list. The notion of nurses being responsible, but without any corresponding power or influence, was a recurring element in the research. In ethical terms, staff nurses are responsible for (and answerable to) others in everything they do. Yet it was clear from discussion that participants’ ability to influence how things are done is constrained by an array of contextual factors. These factors are all underpinned by one common thread – powerlessness. Powerlessness has been described as a central cause and key element in the experience of moral distress.25 This thread links all the themes identified in this study together. Short-staffing was identified as the most pressing environmental factor that constrained participants from fulfilling their ethical obligations. This finding is consistent with the results of the first New Zealand study of nurse moral distress,2 where unsafe staffing levels were reported as causing the greatest intensity of moral distress among nurses who participated in that study. Studies carried out in the United States, Canada and Sweden5,8,34–36 have also found that perceptions of unsafe staffing were associated with the highest frequency and intensity of moral distress and identified as the most stressful ethical issue confronting nurses who participated in those studies. Findings from this study indicate that the capacity of nurses to cope with their workload is tested on a daily basis. Being chronically understaffed appears to have become the baseline for these nurses – particularly on night shifts. Participants’ comments in both meetings and the resignation of one participant from the ward reveal the intensity of the nurses’ moral distress as a result of this situation. That participant described being ‘pushed to the edge’ as a result of the stress that had accumulated during her time in the ward. This fits the pattern of ‘moral residue’ described by Webster and Baylis,37 who used the term to describe the lingering and powerful thoughts and feelings that remain with the individual, following a morally distressing situation. This study found that nursing staff were painted into a corner in ethical terms. Unable to enact their ethical values as a result of unsafe staffing levels and the sheer volume of patient throughput, they also had little opportunity to air their concerns in the hope of addressing these issues. Moral distress was evident in many of the situations described by participants – the result of having to continually compromise in an uncompromising environment. In their systematic review of qualitative evidence on nurse moral distress, Huffman and Rittenmeyer38 point out that there is an organisational culpability associated with the experience of nurse moral distress in hospital environments – irrespective of the specific geographical or cultural context. These researchers 8
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note that moral distress is felt most intensely by nurses when they are obliged to advocate for their patients while coping with institutional constraints on their ethical behaviour. They cite unrealistic and unsafe staffing patterns as being common in nurses’ narratives of situations that give rise to moral distress (p. 97).38 In this instance, the negative effects of short-staffing are magnified by the impact of high patient throughput in the ward. Significantly, this particular issue is a departure from negative climate antecedents reported elsewhere. Although ethical conflict with organisational policies has been recognised as a source of moral distress for nurses,5,39,40 the impact of high patient throughput does not appear to have been singled out as a contributing factor. Instead, policies relating to budget and controlling costs tend to be the focus of attention.5,41,42 Findings from this study illustrate that the participants all perceived the organisation’s main priority to be patient throughput, rather than the quality of patient care. Patients are not just numbers however, as one participant rightly pointed out. Rather, each person has their own unique needs and complexities, which must be taken into account when patients (and nurses) are converted into numbers for business planning purposes. The reason that the high volume of patient throughput has such a negative impact on the nurses’ ability to care for their patients is reflected by Park et al.43 who argue that patient throughput should be included in the equation when nurse staffing levels are determined because of the additional demands it places on nurses’ time. In situations where turnover is high, the nursing workload increases because a more concentrated degree of care is given to a larger number of patients than the total number of beds in the ward indicates.43 Furthermore, this increased workload must be carried out within a shorter timeframe, in order to meet the needs of the increasing number of patients moving through the system.43 As participants in this study explained, although they are told by management that the ward is not short-staffed, their actual bedside experiences strongly indicate otherwise. A significant association has been established between increased patient mortality, high patient turnover and ‘below target’ nurse staffing levels.44 Conversely, higher levels of registered nurse staffing have been linked empirically to lower rates of failure to rescue.43 ‘Failure to Rescue’ refers to patient mortality resulting from preventable complications, including decubitus ulcers, deep vein thrombosis, falls, urinary tract infections, gastrointestinal bleeding and central nervous system complications.45 Mortality is, of course, the extreme consequence of these complications. Finally, of note in the findings from this study was the call from participants for managers to exercise leadership by advocating on behalf of the nursing staff (and their patients). The key role of leaders in facilitating supportive, positive ethical climates has been emphasised in a number of studies.30,46–49 However, a lack of leadership was perceived as a ‘pervasive problem’ in a recent Canadian survey of moral distress and ethical climate.32 In this study, participants’ comments regarding the attitudes and behaviour of some managers towards nursing staff, when staff voice their concerns over safety for example, could suggest that those managers too could be experiencing moral distress.
Limitations This study is limited by its small sample size. Another potential limitation is that all participants were internationally registered nurses, because it could be argued that the added perspective of locally registered nurses may have enhanced the findings. Additionally, the findings are limited to this specific group of participants.
Implications The findings from this study have implications for nurses, their employers and for the nursing profession in New Zealand as a whole. There is an urgent need to raise awareness of the twin concepts of ethical climate 9
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and moral distress among members of the New Zealand nursing workforce at all levels. For ward nurses, it is vital that they recognise and understand why those situations where their moral agency is thwarted have such a resounding and haunting effect on them. For nurse leaders, their key role in promoting a positive ethical climate cannot be overstated. Additionally, the findings from this study should be of particular concern to healthcare managers and policymakers, both at organisational and national levels. These findings illustrate the unintended, but nonetheless significant, downstream consequences at ward (or micro) level of policies that originate at the socio-political (or macro-) level. The detrimental impact on ward nurses’ ethical practice of patient flow initiatives and budgetary policies should not be underestimated. That nurses are experiencing moral distress as a result of such policies indicates that patient care is suffering.
Conclusion To conclude, participants perceived their ward ethical climate in generally unfavourable terms. Although peers within the nursing team were perceived as being extremely supportive and nurses had a good rapport with their medical colleagues, three dominant, negative factors had a synergistic effect in shaping the ward’s ethical climate. These interrelated factors were inadequate staffing, high patient throughput and the attitude of some managers towards nursing staff when concerns were raised about staffing and patient safety. While the findings from this study with regard to staffing levels and the power dynamics between nurses and managers support those from ethical climate research carried out overseas, of note is the impact of patient turnover policy on local nurses’ ethical practice. This issue has not been singled out as having a detrimental influence on ethical climates elsewhere. Compromised patient care was identified as the most prevalent ethical issue nurses confronted in their daily practice, while short-staffing was the most common factor affecting nurses’ ethical practice. Clearly, these nurses do not have a choice in this situation; their hands are tied as a result of constraints within this particular ethical climate. Here, the negative influences far outweigh the positive elements. Conflict of interest The authors declare that there is no conflict of interest. Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors. References 1. New Zealand Nurses Organisation. Code of ethics. Wellington, New Zealand: NZNO, 2010, http://www.nzno. org.nz (2010, accessed November 2012). 2. Woods M, Rodgers V, Towers A, et al. Researching moral distress among New Zealand nurses: a national survey. Nurs Ethics. Epub ahead of print 7 August 2014. DOI: 10.1177/0969733014542679. 3. Olson LL. Hospital nurses’ perceptions of the ethical climate of their work setting. Image J Nurs Sch 1998; 30(4): 345–349. 4. Ulrich C, O’Donnell P, Taylor C, et al. Ethical climate, ethics stress, and the job satisfaction of nurses and social workers in the United States. Soc Sci Med 2007; 65(8): 1708–1719. 5. Corley MC, Minick P, Elswick RK, et al. Nurse moral distress and ethical work environment. Nurs Ethics 2005; 12(4): 381–390. 6. Hamric AB and Blackhall LJ. Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med 2007; 35(2): 422–429. 10
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