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Nurse middle manager ethical dilemmas and moral distress Freda D Ganz, Nurit Wagner and Orly Toren Nurs Ethics published online 29 January 2014 DOI: 10.1177/0969733013515490 The online version of this article can be found at: http://nej.sagepub.com/content/early/2014/01/26/0969733013515490

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Article

Nurse middle manager ethical dilemmas and moral distress

Nursing Ethics 1–9 ª The Author(s) 2014 Reprints and permission: sagepub.co.uk/journalsPermissions.nav 10.1177/0969733013515490 nej.sagepub.com

Freda D Ganz Hadassah Hebrew University School of Nursing, Faculty of Medicine, Jerusalem, Israel

Nurit Wagner Israel National Nurses’ Association Ethics Bureau, Israel

Orly Toren Hadassah Medical Organization, Israel

Abstract Background: Nurse managers are placed in a unique position within the healthcare system where they greatly impact upon the nursing work environment. Ethical dilemmas and moral distress have been reported for staff nurses but not for nurse middle managers. Objective: To describe ethical dilemmas and moral distress among nurse middle managers arising from situations of ethical conflict. Methods: The Ethical Dilemmas in Nursing–Middle Manager Questionnaire and a personal characteristics questionnaire were administered to a convenience sample of middle managers from four hospitals in Israel. Results: Middle managers report low to moderate levels of frequency and intensity of ethical dilemmas and moral distress. Highest scores were for administrative dilemmas. Conclusion: Middle managers experience lower levels of ethical dilemmas and moral distress than staff nurses, which are irrespective of their personal characteristics. Interventions should be developed, studied, and then incorporated into institutional frameworks in order to improve this situation. Keywords Ethical dilemma, moral distress, nurse middle manager

Background A healthy work environment has been described as a joyful place of employment that is supportive of the whole person and is patient focused.1 One aspect of this environment is the ethical environment, defined as a place where ethical values guide the organization in its management of staff and treatment of patients.2 The creation of this environment is a shared endeavor, where individual ethics influence the group, and vice versa.3 The nurse middle manager (assistant head nurse/nurse manager, head nurse/nurse manager, or supervisor) is a major contributor to the work environment. The middle manager plays a pivotal role in creating and

Corresponding author: Freda D Ganz, School of Nursing, Faculty of Medicine, Henrietta Szold Hadassah Hebrew University, P.O. Box 12000, Jerusalem, 91120 Israel. Email: [email protected]

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facilitating an ethical work environment where nurses can provide quality patient care.1,4,5 The current role of the nurse manager is not only to supervise the smooth day-to-day running of the unit and ensure quality care but also to allocate resources.6 This quality of care can be affected by the ethical culture of the unit that is very susceptible to the beliefs as well as actions of the nurse manager.7 There is a dual loyalty inherent to the role of the nurse manager, where there is a tension between the needs and values of the organization and those of the nurses, patients, and families.3–5,8 Nurse managers are socialized as nurses, yet they are expected to act as representatives of their organization.8 Conflicts arise between clinical nursing values (where quality of patient care is primary) and organizational values (where competition, cost, and productivity are stressed).6 Increasing technologies,9 complexity of the healthcare environment,5 and increased emphasis on the efficiency, efficacy, and productivity of healthcare organizations have led to increased value conflicts where moral and ethical challenges have become a normal part of the hospital environment.3 Nurses are especially affected by these challenges as our nursing values are humanistic in nature.9 These issues are reflected in the European Union’s Code of Ethics for Nursing Directors.10 This code discusses the ethical basis of basic values and ethical principles of practice that are associated with the roles of nursing directors and managers. Ethical conflict is created when nurse managers are told to do something that is in opposition to their personal ethical values and principles by those with more power in the organization.8,11,12 Ethical conflict can therefore be defined as a clash between personal values with those of the employing organization.8 Such ethical conflicts can lead to ethical dilemmas and moral distress.13 Moral distress has been defined as negative feelings of psychological disequilibrium associated with situations in which the nurse knows the morally appropriate action to take, but is constrained from doing so due to institutional obstacles.14,15 Moral distress has been investigated among nurses over the past 20 years in both qualitative16 and quantitative17–22 studies. All of these studies have investigated either staff nurses or nurse practitioners in various healthcare settings. None have investigated nurse managers. Nurses are often confronted with ethical dilemmas where the nurse is expected to choose between unsatisfactory alternatives. The nurse is conflicted because each of the opposing choices is ethically supported while each of the opposing choices is also considered ethically problematic. Some information supports both choices as being morally right, while other evidence suggests that the same choices are morally wrong.23 The nurse, therefore, has difficulty deciding between two or more choices that are equally unsatisfactory. Ethical conflicts have been divided into three categories:24 (a) clinical situations such as inappropriate care, (b) interpersonal situations, and (c) administrative situations. Ethical conflicts have been reported by nurse administrators where their values of fairness, faithfulness to duty, and doing good have been shown to conflict with their responsibility to support their organization or balance costs.25 Another study26 found that nurse executives experienced conflict between organizational and individual ethics, especially when they could not provide quality care due to organizational constraints. No other more recent studies were found that addressed this topic. The environment of healthcare in Israel is western in nature. Since 1995, the entire population of Israel receives by law a comprehensive level of health insurance coverage.27 Nursing services are regulated through the Nursing Division of the Ministry of Health. The Israeli Nurses’ Association supports an Ethics Bureau that has published a nursing code of ethics.28 Several Israeli studies have investigated moral distress/ethical dilemmas among Israeli nurses,19,27,29,30 but none have been aimed specifically at nurse managers. In summary, given their position within healthcare organizations, nurse managers have been shown to be susceptible to ethical dilemmas and moral distress arising from ethical conflicts. Both ethical dilemmas and moral distress impact on quality of patient care and on the nurse work environment. However, no studies were found that directly investigated the frequency and intensity of ethical dilemmas and moral distress among nurse managers. Therefore, the objective of this study was to describe ethical dilemmas and moral distress arising from ethical conflicts among nurse middle managers. 2

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Method Sample This study was a cross-sectional survey of middle nurse managers from four hospitals in Israel, two community and two tertiary hospitals. Inclusion criteria were nurses who worked as assistant head nurses/assistant nurse managers, head nurses/nurse managers, and nursing supervisors who worked at the hospitals where the survey was conducted. A convenience sample was taken from all nurses meeting these criteria. A power analysis determined that with an expected weak to moderate effect size, alpha level of 0.05, and a power of 0.8, a minimum of 85 nurses would be needed to participate in the study.

Instruments The study utilized two questionnaires, a personal characteristics questionnaire and the Ethical Dilemmas in Nursing–Middle Manager (EDN-MM) Questionnaire. The personal characteristics questionnaire included questions related to age, gender, place of birth, religion, and religiosity (used as a measure of ethnicity in this population that describes the extent to which the participant adheres to religious practices and is categorized as religious, traditional, or secular), family status, unit, professional education, years of total nursing experience, and years of experience in the current nursing role. The EDN-MM is a questionnaire that describes the level of ethical dilemmas and moral distress arising from ethical conflicts associated with the middle manager role (assistant head nurse, head nurse, and supervisor roles). The original EDN24 questionnaire was developed for use with staff nurses. The current questionnaire adapted the original EDN questionnaire so that items would be more appropriate for use with middle managers instead of staff nurses. The title of the questionnaire implies that the tool was composed only of ethical dilemmas. However, based on a more current review of the literature, many of the items also describe ethical conflicts that lead to moral distress. The original EDN was composed of 39 items, divided into three subscales: clinical–professional, interpersonal, and administrative. It has been used in four previous Israeli studies.19,27,29,30 The revised EDN for middle managers (EDN-MM) includes the original items of the EDN with an additional 22 items related to areas of concern to middle managers, for a total of 61 items. Each item is scored using two different Likert scales: one scale measures frequency (on a scale from 1 (never) to 4 (frequently)) and the second scale measures intensity (on a scale from 0 (not relevant) to 6 (extremely intense)). The EDN-MM was reviewed for content validity by nurse ethicists and managers. A pilot test was conducted to determine the tool’s feasibility and ease of administration. Cronbach’s a reliability for this study for the entire tool was found to be 0.93 for the frequency scale and 0.95 for the intensity scale. The clinical–professional subscale is composed of 28 items (Cronbach’s a: frequency ¼ 0.87, intensity ¼ 0.90 in this study), divided into five sections: treatment decisions (6 items), procedures done against the wish of the patient/family (5 items), confidentiality and items related to transfer of patient information (6 items), reporting of medical errors (3 items), and inequitable medical treatment (8 items). The interpersonal subscale contains 11 items related to inappropriate behavior of patients/families to providers (3 items), conflicts between patients and their families (2 items), and inappropriate behavior of staff toward patients/families (6 items). Cronbach’s a values for this study were a ¼ 0.72 for frequency and a ¼ 0.79 for intensity. The administrative subscale contains four sections: delay of medical treatment not related to the patient’s medical condition (4 items), management of patient care (4 items), management of staff (6 items), and administration of organizational policy and budget (8 items) (Cronbach’s a: frequency ¼ 0.87, intensity ¼ 0.89 in this study). 3

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Data collection and ethical review Administration and institutional research ethics committee approval were obtained at all four hospitals. Nurses were advised of the anonymity and confidentiality of the data and their ability to refuse to participate. Questionnaires were distributed during a regularly scheduled meeting of the nursing administration at each institution. Managers were asked to complete the questionnaire and return it in an unmarked envelope at the end of the meeting. Data collection took place in 2011–2012.

Data analysis Descriptive statistics were used to describe the sample and the frequency data of the questionnaires. For additional findings, relationships between interval-level personal characteristics (such as age and nursing experience) and ethical dilemmas and moral distress were analyzed using Pearson’s product–moment correlations or analysis of variance (for nominal-level data).

Results The mean age of participants was 46.9 years (standard deviation (SD) ¼ 8.7 years). The majority of the sample were women (n ¼ 118, 91.5%), Jewish (n ¼ 109, 87.9%), and married (n ¼ 109, 84.5%). Most were head nurses (n ¼ 78, 60.5%) who had worked a mean of 23.3 years (SD ¼ 9.0 years), with a mean of 15.7 years (SD ¼ 9.9 years) in their current place of employment and 7.9 years in the current role (SD ¼ 7.7 years). Almost the entire sample had an academic education (97.2%) with some form of post-basic certification (95.9%) (Table 1). Mean item frequencies ranged from 1.05 to 2.86, where the highest possible mean score was 4. The administration subscale had the highest frequency item mean among the three subscales (M ¼ 2.0, SD ¼ 0.4) (Table 2). Seven items had mean frequency scores above 2.5, with 5 out of the 7 in the administration subscale. Details of the 10 highest and lowest frequency items are found in Table 3. Nine out of 10 of the highest frequency scoring items also scored highest in intensity, while all of the lowest scoring frequency items also scored lowest in intensity. Mean item intensity levels ranged from 0.3 to 4.4, where the highest possible mean score was 6. The highest level of intensity of ethical dilemma/moral distress was felt in the administration subscale (M ¼ 2.6, SD ¼ 1.2) (see Table 2). Details of the 10 highest and lowest intensity items are found in Table 4. The only personal characteristics found to be related to either frequency or intensity of ethical dilemmas/moral distress were the nursing role and unit, where the interpersonal subscale frequency scores differed between assistant head nurses and supervisors (F(3, 114) ¼ 4.43, p ¼ .006) and between units (F(9, 106) ¼ 3.05, p ¼ .003). While the overall statistical test for differences between units was found significant, post hoc analysis using the Bonferroni test revealed no significant differences between two specific types of units.

Discussion Nurse managers in this study rarely encountered ethical dilemmas or moral distress; however, when confronted with such situations, they felt a low to moderate level of intense feelings. The most common and most distressing dilemmas were administrative. Personal characteristics were not related to these feelings. Higher levels of moral distress intensity as opposed to frequency have also been found in other populations of staff nurses all over the world.18,31,32 These results seem to be consistently found among nurses from different countries with varying cultures and healthcare systems. Therefore, it might be concluded that ethical conflicts might be a product of the essence of the work of nursing and not of a specific culture or healthcare system. 4

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Table 1. Sample personal and professional characteristics (N ¼ 133). Personal characteristic

n (%)

Religion Jewish Moslem Other Missing Religiosity Ultra orthodox Religious Traditional Secular Missing Marital status Single Married Divorced Widowed Missing Place of birth Israel Former USSR North America and South America Europe Other Missing RN education RN RN þ BSN RN þ MA

Professional characteristic

109 (87.9) 9 (7.3) 6 (4.8) 9 1 (0.8) 22 (17.2) 38 (29.7) 66 (51.6) 5 8 (4.7) 109 (84.5) 12 (9.3) 2 (1.6) 4 79 (61.7) 26 (20.3) 7 (5.5) 7 (5.5) 5 (3.9) 5

n (%)

Role Assistant head nurse Head nurse Supervisor Other Missing Unit Surgery Medicine Oncology Critical care Maternity Pediatrics OR and PACU Outpatient Other Missing % FTE 50 75 100 Missing

33 (25.6) 78 (60.5) 7 (5.3) 11 (8.5) 4 25 (20.8) 20 (16.7) 11 (9.2) 10 (8.3) 8 (6.7) 7 (5.8) 7 (5.8) 7 (5.8) 25 (20.8) 13 1 (0.8) 3 (2.3) 125 (96.9) 4

5 (3.8) 67 (51.5) 58 (44.6)

OR: operating room; PACU: postoperative care unit; FTA: full-time equivalent; USSR: Union of Soviet Socialist Republics; RN: registered nurse; BSN: Bachelor of Science in Nursing.

Table 2. Ethical dilemma/moral distress frequency and intensity scores by subscales (N ¼ 133). Frequency

Intensity

Subscale

Sum

Item M

SD

Sum

Item M

SD

Clinical–professional (28 items) Interpersonal (11 items) Administration (22 items) Total (61 items)

43.0 18.5 43.4 103.0

1.5 1.7 2.0 1.7

0.3 0.3 0.4 0.3

45.4 23.2 58.1 122.4

1.6 2.1 2.6 2.3

1.0 1.1 1.2 1.0

Ethical dilemma and moral distress frequency and intensity responses of the mangers tended to be slightly lower than those reported for staff nurses in two of the three categories (clinical–professional and interpersonal).19 These slightly lower scores could reflect differences in the role of the manager as opposed to the staff nurse. Managers might be more removed from day-to-day clinical practice. Nurse managers see the staff as their primary responsibility followed by ensuring safe and quality patient care. 5

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Table 3. Highest and lowest scoring frequency items (scale 1–4). Item Number

Item

Mean (SD)

Highest scoring frequency items 49 Lack of balance between patient care and administrative dutiesa 48 Pressure to admit patients above the approved number of beds on the unita 4 Need to take care of an insulting and hurtful patienta 11 Inability to provide good care due to lack of staff a 50 Administrative directives that are not appropriate for the clinical areaa 33 Conflicts between the needs of an individual nurse and the unita 19 Patient/family violence against a nursea 46 Lack of equipmenta 5 Preferential treatment of patient due to connections 32 Conflicts between the needs of the patient and the familya Lowest scoring frequency items 42 Performing research without the patient’s consentb 56 Use of money and presents to improve patient careb 15 Conducting tests for research without patient consentb 20 Sexual harassment of a patientb 59 Use of alcohol or drugs by the staff b 27 Purposely providing incorrect diagnosis information to a patientb 54 Discriminatory treatment of a prisonerb 57 Mishandling of fundsb

2.86 (0.95) 2.83 (1.14) 2.73 (0.79) 2.73 (0.95) 2.68 (0.86) 2.55 (0.86) 2.52 (0.76) 2.35 (0.92) 2.23 (0.99) 2.13 (0.82) 1.05 (0.26) 1.07 (0.29) 1.11 (0.38) 1.11 (0.31) 1.12 (0.41) 1.14 (0.37) 1.14 (0.45) 1.20 (0.51)

a

Scored among the highest items in both frequency and intensity. Scored among the lowest items in both frequency and intensity.

b

However, the highest intensity and frequency scores were found for the administrative subscale. The mean scores on this subscale in this study were similar to the level of mean scores found in a study of staff nurses.19 While not using the same identical questionnaire, both studies were based on the EDN, where the trend in the data is similar. This scale might more directly reflect those situations encountered by the nurse manager. Similar findings were found by others. In a survey of ethical dilemmas among nurse administrators, staffing level and mix, development of standards of care, and allocation of scarce resources were found to be the most salient dilemmas followed by interpersonal areas such as firing employees and interpersonal relationships.25 These results are also similar to two more recent studies. The first, a survey of American nurse executives,26 found that failure to provide quality patient care due to conflicts between individual and organizational values was the largest source of ethical conflict in their role as administrators. These results are partially explained by an Israeli study29 that found that nurse managers tended to place a lower level of importance on organizational values as opposed to personal values, thereby leading to conflicts between the needs of the institution and the individual. The second study,33 conducted in Finland, found that the most common ethical problems were resource allocation and providing and developing quality nursing care. Several items were found to score highest in both levels of frequency and intensity. Two items are indicative of the unique position of the nurse manager in the healthcare organization: (a) the difficulty associated with trying to balance time requirements between patient care and running of the unit and time for administrative tasks and (b) conflicts between the needs of the unit and an individual nurse. A qualitative survey6 of Swedish nurse managers also found that subjects wanted more time to give to staff and day-today work of unit. Another item found relatively high in both frequency and intensity was inappropriate behavior by patients and families against nurses. This problem seems to be consistent over time as the three previous 6

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Table 4. Highest and lowest scoring intensity items (scale 0–6). Item Number

Item

Mean (SD)

Highest scoring intensity items 19 Patient/family violence against a nursea 11 Inability to provide good care due to lack of staff a 50 Administrative directives that are not appropriate for the clinical areaa 49 Lack of balance between patient care and administrative dutiesa 33 Conflicts between the needs of an individual nurse and the unita 23 Impolite behavior of a nurse to a patient 45 Impolite behavior of a nurse to another staff member 46 Lack of equipmenta 4 Need to take care of insulting and hurtful patienta 32 Conflicts between the needs of the patient and the familya 48 Pressure to admit patients above the approved number of beds on the unita Lowest scoring intensity items 42 Performing research without the patient’s consentb 56 Use of money and presents to improve patient careb 15 Conducting tests for research without patient consentb 54 Discriminatory treatment of a prisonerb 59 Use of alcohol or drugs by the staff b 57 Mishandling of fundsb 27 Purposely providing incorrect diagnosis information to a patientb 20 Sexual harassment of a patientb 14 Not documenting for fear of stigmatizing a patient 1 Nurse refusal to take care of patient that could endanger the nurse

4.44 (1.85) 4.00 (2.06) 3.90 (1.90) 3.79 (2.04) 3.68 (1.91) 3.67 (2.42) 3.47 (2.44) 3.46 (2.10) 3.36 (1.69) 3.30 (2.20) 3.08 (2.20) 0.31 (1.07) 0.32 (1.14) 0.42 (1.13) 0.42 (1.31) 0.45 (1.42) 0.61 (1.48) 0.65 (1.55) 0.71 (1.77) 0.88 (1.62) 0.90 (1.44)

a

Scored among the highest items in both frequency and intensity. Scored among the lowest items in both frequency and intensity.

b

studies that used the EDN that were conducted in a span of over 15 years also found that this dilemma was either ranked highest19,30 or one among the top five dilemmas.25 This problem has also increased around the world with increased reporting of patient and family verbal and physical abuse to healthcare staff.34–36 A fourth high scoring item was inability to deliver quality care due to low staffing. The nursing shortage is a global problem that also applies to Israel.37 Other studies have also shown that demographic characteristics such as age and gender do not tend to be associated with levels of moral distress.33,38 This might imply that ethical dilemmas and moral distress might be more associated with the healthcare environment3 and other personal characteristics such as personality or coping mechanisms. This study, as in all other studies, has its limitations. The sample was a relatively small convenience sample taken from only four institutions. However, the hospitals were from different areas of the country and included tertiary and community hospitals. The tool used to measure ethical dilemmas/moral distress was adapted for this study, and while demonstrating adequate content validity and internal consistency reliability, further investigation of its psychometric properties is recommended on other samples and other populations. Other intervening variables that impact on this relationship should also be tested, such as variables related to the work environment, healthcare system, and personality characteristics of the individual nurses. Policy decisions such as zero tolerance for verbal or physical abuse or creation of more ethical work environments should be encouraged and investigated to determine their impact on ethical dilemmas/moral distress. Interventions can be designed to decrease levels of moral distress/ethical dilemmas among nurse managers. 7

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Conclusion Levels of ethical dilemma/moral distress frequency and intensity were found among nurse managers that were lower than those reported among different populations of staff nurses around the world, except for administrative issues. Therefore, attempts should especially focus on investigating and improving the administrative aspects of the nurse manager ethical work environment. Personal and professional characteristics were not associated with levels of ethical dilemmas/more distress; therefore, this problem might be ubiquitous and could be addressed universally. Administrative actions and other research-supported interventions aimed at decreasing these responses might therefore lead to improvements in quality of nursing care. Conflict of interest The authors declare that there is no conflict of interest. Funding This study was funded by the Israel National Nurses’ Association Ethics Bureau. References 1. Espinoza DC, Lopez-Saldana A and Stonestreet JS. The pivotal role of the nurse manager in healthy workplaces implications for training and development. Crit Care Nurs Q 2008; 32(4): 327–334. 2. Corley MC, Minick P, Elswick R, et al. Nurse moral distress and ethical work environment. Nurs Ethics 2005; 12(4): 381–390. 3. Hardingham LB. Integrity and moral residue: nurses as participants in a moral community. Nurs Philos 2004; 5: 127–134. 4. Toren O and Wagner N. Applying an ethical decision-making tool to a nurse management dilemma. Nurs Ethics 2010; 17(3): 393–402. 5. Edmonson C. Moral courage and the nurse leader. Online J Issues Nurs 2010; 15: 3. 6. Skytt B, Ljungren B and Carlsson M. The roles of the first-line nurse manager: perceptions from four perspectives. J Nurs Manag 2008; 16: 1012–1020. 7. Wlody GS. Nursing management and organizational ethics in the intensive care unit. Crit Care Med 2007; 35: S29–S35. 8. Gaudine AP and Beaton MR. Employed to go against ones’ values: nurse managers’ accounts of ethical conflict with their organizations. Can J Nurs Res 2002; 34(2): 17–34. 9. Schluter J, Winch S, Holzhauser K, et al. Nurses’ moral sensitivity and hospital ethical climate: a literature review. Nurs Ethics 2008; 15(3): 304–321. 10. Stievano A, DeMarinis MG, Kelly D, et al. A proto-code of ethics and conduct for European nurse directors. Nurs Ethics 2012; 19(2): 279–288. 11. Atkinson D, Bailey S and Seden J. The ‘‘Morally Active’’ manager. Nurs Manag 2003; 10(6): 31–34. 12. Brosnan J and Roper JM. The reality of political ethical conflicts: nurse manager dilemmas. J Nurs Admin 1997; 27(9): 42–46. 13. Erlen JA. Moral distress: a pervasive problem. Orthop Nurs 2001; 20(2): 76–80. 14. Jameton A. Nursing practice: the ethical issues. Englewood Cliffs, NJ: Prentice Hall, 1984. 15. Kopala B and Burkhart L. Ethical dilemma and moral distress: proposed new NANDA diagnoses. Int J Nurs Terminol Classif 2005; 16: 3–13. 16. Rittenmeyer L and Huffman D. How professional nurses working in hospital environments experience moral distress: a systematic review. JBI Lib Syst Rev 2009; 7(28): 1233–1290. 8

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17. Corely MC, Elswick RK, Gorman M, et al. Development and evaluation of the moral distress scale. J Adv Nurs 2001; 33(2): 250–256. 18. Elpern EH, Covert B and Kleinpell R. Moral distress of staff nurses in a medical intensive care unit. Am J Crit Care 2005; 14: 523–530. 19. Ganz DF and Berkovitz K. Surgical nurses’ perceptions of ethical dilemmas, moral distress and quality of care. J Adv Nurs 2012; 68(7): 1516–1525. 20. Laabs CA. Moral problems and distress among nurse practitioners in primary care. J Am Acad Nurse Pract 2005; 17(2): 76–84. 21. Shorideh FA, Ashktorab T and Yaghmaei F. Iranian intensive care unit nurses’ moral distress: a content analysis. Nurs Ethics 2012; 19(4): 464–478. 22. Wiegand DL and Funk M. Consequences of clinical situations that cause critical care nurses to experience moral distress. Nurs Ethics 2012; 19(4): 479–487. 23. Corley MC. Nurse moral distress: a proposed theory and research agenda. Nurs Ethics 2002; 9(6): 636–650. 24. Wagner N and Ronen I. Ethical dilemmas experienced by hospital and community nurses: an Israeli survey. Nurs Ethics 1996; 3(4): 294–302. 25. Borawski DB. Ethical dilemmas for nurse administrators. J Nurs Admin 1995; 25(7–8): 60–62. 26. Cooper RW, Frank GL, Hansen MM, et al. Key ethical issues encountered in healthcare organizations: the perceptions of staff nurses and nurse leaders. J Nurs Admin 2004; 34(3): 149–156. 27. Hendel T and Wagner N. Nursing ethics from a bi-cultural perspective: a comparison survey. J Multicult Nurs Health 1998; 4(1): 16–21. 28. Israel Nurses Association Ethics Bureau. Israel code of nursing ethics. Tel Aviv, Israel: Israel Nurses Association Ethics Bureau, 2004. 29. Hendel T and Steinman M. Israeli nurse managers’ organizational values in today’s health care environment. Nurs Ethics 2002; 9(6): 651–662. 30. Wagner N and Hendel T. Ethics in pediatric nursing: an international perspective. J Ped Nurs 2000; 15(1): 54–59. 31. Kalvemark SS, Hoglund AT, Hansson MG, et al. Living with conflicts-ethical dilemmas and moral distress in the health care system. Soc Sci Med 2004; 58(6): 1075–1084. 32. Rice EM, Rady MY, Hamrick A, et al. Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. J Nurs Manag 2008; 16(3): 360–373. 33. Aitamma E, Leino-Kilpi H, Puukka P, et al. Ethical problems in nursing management: the role of codes of ethics. Nurs Ethics 2010; 17(4): 469–482. 34. Camerino D, Estryn-Behar M, Conway PM, et al. Work related factors and violence among nursing staff in the European NEXT study: a longitudinal cohort study. Int J Nurs Stud 2008; 45(1): 35–50. 35. Kisa S. Turkish nurses’ experience of verbal abuse at work. Arch Psych Nurs 2008; 22(4): 200–207. 36. Crilly J, Chaboyer W and Creedy D. Violence towards emergency department nurses by patients. Acc Emerg Nurs 2004; 12(2): 67–73. 37. Nursing Division Ministry of Health. Annual report of the nursing division, 2010 (In Hebrew). 38. Maluwa VM, Andre J, Ndebele P, et al. Moral distress in nursing practice in Malawi. Nurs Ethics 2012; 19(2): 196–207.

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Nurse middle manager ethical dilemmas and moral distress.

Nurse managers are placed in a unique position within the healthcare system where they greatly impact upon the nursing work environment. Ethical dilem...
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