Perceived potentially inappropriate treatment in the PICU: frequency, contributing factors and the distress it triggers.

Background: Potentially inappropriate treatment in critically ill adults is associated with healthcare provider distress and burnout. Knowledge regarding perceived potentially inappropriate treatment amongst pediatric healthcare providers is limited. Objectives: Determine the frequency and factors associated with potentially inappropriate treatment in critically ill children as perceived by providers, and describe the factors that providers report contribute to the distress they experience when providing treatment perceived as potentially inappropriate. Methods: Prospective observational mixed-methods study in a single tertiary level PICU conducted between March 2 and September 14, 2018. Patients 0-17 years inclusive with: (1) ≥1 organ system dysfunction (2) moderate to severe mental and physical disabilities, or (3) baseline dependence on medical technology were enrolled if they remained admitted to the PICU for ≥48 h, and were not medically fit for transfer/discharge. The frequency of perceived potentially inappropriate treatment was stratified into three groups based on degree of consensus (1, 2 or 3 providers) regarding the appropriateness of ongoing active treatment per enrolled patient. Distress was self-reported using a 100-point scale. Results: Of 374 patients admitted during the study, 133 satisfied the inclusion-exclusion criteria. Eighteen patients (unanimous - 3 patients, 2 providers - 7 patients; single provider - 8 patients) were perceived as receiving potentially inappropriate treatment; unanimous consensus was associated with 100% mortality on 3-month follow up post PICU discharge. Fifty-three percent of providers experienced distress secondary to providing treatment perceived as potentially inappropriate. Qualitative thematic analysis revealed five themes regarding factors associated with provider distress: (1) suffering including a sense of causing harm, (2) conflict, (3) quality of life, (4) resource utilization, and (5) uncertainty. Conclusions: While treatment perceived as potentially inappropriate was infrequent, provider distress was commonly observed. By identifying specific factor(s) contributing to perceived potentially inappropriate treatment and any associated provider distress, organizations can design, implement and assess targeted interventions.

Development of ethical conflict scale for nurses in extraordinary circumstances and psychometric testing.

AIM: The aim of this study was to develop and psychometrically test the Ethical Conflict Scale for Nurses in Extraordinary Circumstances (ECSNEC). DESIGN: This study is designed to develop and validate an instrument. METHODS: There are four basic steps in the development process of ECSNEC: (1) establishment of the conceptual framework, (2) creation of the item pool, (3) preliminary evaluation and (4) psychometric evaluation. The data were gathered from 519 nurses who worked in two different hospitals operating in Istanbul between June 2022 and October 2022. RESULTS: The scale had good content validity. The exploratory factor analysis revealed a three-factor construct which explained 47.31% of the total variance in the measured variable. The corresponding construct was confirmed by the confirmatory factor analysis. The Cronbach's alpha coefficients were greater than .60 for all dimensions. The test-retest reliability coefficient value of the scale was 0.90. CONCLUSION: ECSNEC is a valid and reliable tool to determine the ethical conflict experienced by nurses in extraordinary circumstances. IMPACT: The established scale allows the identification of factors influencing the ethical challenges nurses face in extraordinary circumstances. Thus, policies can be developed to prevent such ethical conflicts. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Analysis of Moral Emotion from the Perspective of Moral Injury Research / 中国医学伦理学

Moral emotion is a kind of psychological activity that generated when dealing with realistic moral relationship or analyzing human behaviors, expressed as emotional emotions of love and hatred. From the perspective of moral injury research, on the one hand, moral emotion expresses as emotional collapse, which reflects the huge gap between reality and moral cognition, and deviates from values; on the other hand, it shows the typical symptoms of moral injury, such as shame, guilt, anger, apathy and so on. Based on this, the therapy of moral injury should start from solving the ethical conflict of moral injury, and carry out the healing process of "ethical and moral cognitive education, enlightening the thinking of core value issues, encouraging and guiding independent moral practice" in stages according to the different levels of individual moral emotion. As a result, moral emotion can be rational enough to promote healing moral injury.

Assessing Facilitator Fidelity to Principles of Public Deliberation: Tutorial.

Public deliberation, or deliberative democracy, is a method used to elicit informed perspectives and justifiable solutions to ethically fraught or contentious issues that affect multiple stakeholder groups with conflicting interests. Deliberative events bring together stakeholders (deliberants) who are provided with empirical evidence on the central issue or concern and then asked to discuss the evidence, consider the issue from a societal perspective, and collectively work toward a justifiable resolution. There is increasing interest in this method, which warrants clear guidance for evaluating the quality of its use in research. Most of the existing literature on measuring deliberation quality emphasizes the quality of deliberants' inputs (eg, engagement and evidence of compromise) during deliberative sessions. Fewer researchers have framed quality in terms of facilitator inputs, and these researchers tend to examine inputs that are consistent with generic group processes. The theory, process, and purpose of public deliberation, however, are distinct from those of focus groups or other group-based discussions and warrant a mechanism for measuring quality in terms of facilitator fidelity to the principles and processes of deliberative democracy. In our public deliberation on ethical conflicts in minor consent for biomedical HIV prevention research, we assessed facilitator fidelity to these principles and processes because we believe that such assessments serve as a component of a comprehensive evaluation of overall deliberation quality. We examined verbatim facilitator remarks in the deliberation transcripts and determined whether they aligned with the 6 principles of public deliberation: equal participation, respect for the opinions of others, adoption of a societal perspective, reasoned justification of ideas, expression of diverse opinions, and compromise or movement toward consensus. In this tutorial, we describe the development of a blueprint to guide researchers in assessing facilitator fidelity, share 3 templates that will assist them in the task, and describe the results of our assessment of facilitator fidelity in 1 of the 4 sites in which we conducted deliberations.

The experiences of intensive care nurses coping with ethical conflict: a qualitative descriptive study.

BACKGROUND: The critical conditions and life risk scenarios make intensive care nurses susceptible to ethical conflict. Negative consequences were recognized at both the individual level and the professional level which highly compromised the patient care and nurses' well-being. Therefore, ethical conflict has become a major concern in nursing practice. However, the experience of coping with ethical conflict among intensive care nurses remains unclear. AIMS: This study aims to explore the experience of intensive care nurses coping with ethical conflict in China. METHODS: From December 2021 to February 2022, in- depth interviews with 15 intensive care nurses from five intensive care units in a tertiary general hospital in China was performed using purposive sampling. An inductive thematic analysis approach was used to analyze the data. We applied the consolidated criteria for reporting qualitative research for this study. RESULTS: Two distinctive themes were found: detachment and engagement, which contained four subthemes: ignoring ethical problems in the workplace, seeking ways to express emotions, perspective-taking, and identifying positive assets. Theses coping strategies demonstrated an ongoing process with different essential features. CONCLUSION: This study provides a new insight into the experience of intensive care nurses coping with ethical conflict in clinical nursing. Intensive care nurses demonstrated differential experience of coping with ethical conflict including problem-focused, emotion-focused and meaning-making strategies. These findings have implications for policymakers and nursing administrators to develop ethical education and training and supportive environment for intensive care nurses to tackle this issue.

Niveles de burnout y de exposición a conflicto ético de los profesionales de enfermería de cuidados intensivos / Levels of burnout and exposure to ethical conflict and assessment of the practice environment in nursing professionals of intensive care

Introducción: Los profesionales de enfermería que trabajan en unidades de cuidados intensivos (UCI) poseen un alto riesgo de desarrollar respuestas emocionales negativas, así como problemas emocionales y espirituales relacionados con cuestiones éticas. El diseño de estrategias efectivas que mejoren estos aspectos viene determinado por el conocimiento de los niveles de burnout y conflicto ético de dichos profesionales, así como la influencia que el entorno de la práctica puede tener en ellos. Objetivo: Analizar la relación existente entre niveles de burnout, exposición a conflicto ético y la percepción del ambiente de la práctica entre sí y con las variables sociodemográficas de los diferentes profesionales de enfermería de cuidados intensivos. Metodología: Estudio transversal correlacional en una UCI de un hospital universitario de nivel terciario. Se evaluó el nivel de burnout con la escala Maslach Burnout Inventory-Human-Services Survey; el nivel de conflicto ético, con el cuestionario de conflictividad ética para enfermeros, y la percepción del entorno, con la escala Practice-Environment-Scale of the Nursing-Work-Index. La asociación entre variables categóricas ha sido analizada mediante el test exacto de Fisher de chi-cuadrado (χ2). Resultados: Se evaluaron 39 enfermeras y 8 auxiliares, obteniendo una tasa de participación del 82,93%. El 31,10% de los profesionales de enfermería presentaron signos de burnout, el 14,89% consideraron que trabajan en un entorno desfavorable y el 87,23% presentaron un índice de exposición a conflicto ético medio-alto.El nivel educativo (χ2=11,084, p=0,011) y la categoría profesional (χ2=5,007, p=0,025) influyeron en el nivel de burnout, presentando las auxiliares mayores niveles del mismo...(AU)

Background: Nursing professionals working in intensive care units (ICU) are at high risk of developing negative emotional responses as well as emotional and spiritual problems related to ethical issues. The design of effective strategies that improve these aspects is determined by knowing the levels of burnout and ethical conflict of these professionals, as well as the influence that the practice environment might have on them. Objectives: To analyze the relationship between levels of burnout, the exposure to ethical conflicts and the perception of the practice environment among themselves and with sociodemographic variables of the different intensive care nursing professionals. Methods: Descriptive, correlational, cross-sectional, observational study in an ICU of a tertiary level university hospital. The level of burnout was evaluated with the Maslach Burnout Inventory Human Services Survey scale; the level of ethical conflict with the Ethical Conflict Questionnaire for Nurses; and the perception of the environment with the Practice Environment Scale of the Nursing Work Index. Descriptive and inferential statistics were performed. The association between categorical variables was analyzed using Fisher's exact chi-square test (χ2). Results: 31 nurses and 8 nursing assistants were evaluated, which meant a participation rate of 82.93%. 31.10% of the nursing professionals presented signs of burnout, 14.89% considered that they work in an unfavorable environment and 87.23% presented a medium-high index of exposure to ethical conflict. The educational level (χ2=11.084, P=.011) and the professional category (χ2=5.007, P=.025) influenced the level of burnout: nursing assistants presented higher levels of this. When comparing the level of burnout with the environment and the index of ethical conflict, there were no statistically significant differences...(AU)

A semantic exploration: Nurse ethicist, medical ethicist, or clinical ethicist: Do distinctions matter?

Since the 1960s, it has been recognized that "medical ethics," the area of inquiry about the obligations of practitioners of medicine, is inadequate for capturing and addressing the complexities associated with modern medicine, human health, and wellbeing. Subsequently, a new specialty emerged which involved scholars and professionals from a variety of disciplines who had an interest in healthcare ethics. The name adopted is variously biomedical ethics or bioethics. The practice of bioethics in clinical settings is clinical ethics and its primary aim is to resolve patient care issues and conflicts. Nurses are among these clinical ethicists. They are drawn to the study and practice of bioethics and its applications as way to address the problems encountered in practice. A significant number are among the ranks of clinical ethicists. However, in the role of bio- or clinical ethicist, some retained the title of their original profession, calling themselves nurse ethicists, and some did not. In this article, we explore under which conditions it is permissible or preferable that one retains one's prior profession's nomenclature as a prefix to "ethicist," under which conditions it is not, and why. We emphasize the need for transparency of purpose related to titles and their possible influence on individual and social good.

Levels of burnout and exposure to ethical conflict and assessment of the practice environment in nursing professionals of intensive care.

BACKGROUND: Nursing professionals working in Intensive Care Units (ICU) are at high risk of developing negative emotional responses as well as emotional and spiritual problems related to ethical issues. The design of effective strategies that improve these aspects is determined by knowing the levels of burnout and ethical conflict of these professionals, as well as the influence that the practice environment might have on them. OBJECTIVES: To analyze the relationship between levels of burnout, the exposure to ethical conflicts and the perception of the practice environment among themselves and with sociodemographic variables of the different intensive care nursing professionals. METHODS: Descriptive, correlational, cross-sectional, observational study in an ICU of a tertiary level university hospital. The level of burnout was evaluated with the Maslach Burnout Inventory Human Services Survey scale; the level of ethical conflict with the Ethical Conflict Questionnaire for Nurses and the perception of the environment with the Practice Environment Scale of the Nursing Work Index. Descriptive and inferential statistics were performed. The association between categorical variables was analyzed using Fisher's exact chi-square test (χ2) RESULTS: 31 nurses and 8 nursing assistants were evaluated, which meant a participation rate of 82,93%. 31,10% of the nursing professionals presented signs of burnout, 14,89% considered that they work in an unfavorable environment and 87,23% presented a medium-high index of exposure to ethical conflict. The educational level (χ2=11.084, p=0.011) and the professional category (χ2=5.007, p=0.025) influenced the level of burnout: nursing assistants presented higher levels of this. When comparing the level of burnout with the environment and the index of ethical conflict, there were no statistically significant differences. CONCLUSIONS: The absence of association found in the study between Burnout and ethical conflict with the perception of the practice environment suggests that personal factors may influence its development.

Oncology residents' experiences of decision-making in a clinical learning environment: a phenomenological study.

Oncology residents routinely engage in ethically complex decision-making discussions with patients, while observing and interacting with their teaching consultant. If clinical competency in oncology decision-making guidance is to be taught deliberately and effectively, it is necessary to understand resident experiences in this context to develop appropriate educational and faculty development initiatives. Four junior and two senior postgraduate oncology residents participated in semi-structured interviews during October and November 2021 which explored their experiences of real-world decision-making scenarios. Van Manen's phenomenology of practice was used in an interpretivist research paradigm. Transcripts were analysed to articulate essential experiential themes, and composite vocative narratives were created. Three essential themes were identified: (1) residents often endorsed different decision-making approaches than supervising consultants, (2) residents experienced inner conflict, and (3) residents struggled to find their own approach to decision-making. Residents experienced being torn between a perceived obligation to defer to consultant directives, and a desire for increasing ownership of decision-making while not feeling empowered to discuss their opinions with the consultants. Residents described their experiences around ethical position awareness during decision-making in a clinical teaching context as challenging, with experiences suggesting moral distress combined with inadequate psychological safety to address ethical conflicts and unresolved questions of decision ownership with supervisors. These results suggest the need for enhanced dialogue and more research to reduce resident distress during oncology decision-making. Future research should be aimed at discovering novel ways in which residents and consultants could interact in a unique clinical learning context including graduated autonomy, a hierarchical gradient, ethical positions, physician values, and sharing of responsibility.

COVID-19 pandemic experiences, ethical conflict and decision-making process in critical care professionals (Quali-Ethics-COVID-19 research part 1): An international qualitative study.

AIM AND OBJECTIVES: The aim of this study was to explore the sources of ethical conflict and the decision-making processes of ICU nurses and physicians during the first and subsequent waves of the COVID-19 pandemic. BACKGROUND: Depside several studies exploring ethical conflicts during COVID-19 pandemic, few studies have explored in depth the perceptions and experiences of critical care professionals regarding these conflicts, the decision-making process or which have analysed the complexity of actually implementing the recommendations of scientific societies and professional/healthcare institutions in interdisciplinary samples. DESIGN: A descriptive phenomenological study. METHODS: Thirty-eight in-depth interviews were conducted with critical care nurses and physicians from five hospitals in Spain and Italy between December 2020 and May 2021. A thematic content analysis of the interview transcripts was conducted by two researchers. Consolidated criteria for reporting qualitative research (COREQ) were employed to ensure the quality and transparency of this study. RESULTS: Two main themes emerged as sources of ethical conflict: the approach to end of life in exceptional circumstances and the lack of humanisation and care resources. The former comprised two subthemes: end-of-life care and withholding and withdrawal of life-sustaining treatment; the latter comprised three subthemes: the impossibility of guaranteeing the same opportunities to all, fear of contagion as a barrier to taking decisions and the need to humanise care. CONCLUSIONS: Professionals sought to take their decisions in line with professional ethics and bioethical principles, but, nevertheless, they experienced moral dilemmas and moral distress when not being able to care for, or to treat, their patients as they believed fit. RELEVANCE TO CLINICAL PRACTICE: Further education and training are recommended on the provision of end-of-life and post-mortem care, effective communication techniques via video calls, disclosure of bad news and bioethical models for decision-making in highly demanding situations of uncertainty, such as those experienced during the COVID-19 pandemic.

Ethical conflict in nursing: A concept analysis.

AIMS AND OBJECTIVES: The purpose of this paper was to clarify the concept of ethical conflict in nursing and highlight the importance of tackling this issue. BACKGROUND: Ethical conflict is on the rise in the nursing context. It is associated with the compromise of nurses' well-being and patient care. However, there is no thorough conceptual understanding of this concept. DESIGN: Concept analysis. METHODS: Databases (PubMed, PsycINFO, CINAHL, Scopus, Embase, Web of Science and SocINDEX) were searched for studies between 1984 and 2021. Both quantitative and qualitative studies related to ethical conflict in nursing were included. Walker and Avant's method of concept analysis was used to identify the defining attributes, antecedents and consequences of the concept of ethical conflict in nursing. We followed the PRISMA-ScR checklist to report the study. RESULTS: Thirty studies were included for conceptualization. Defining attributes were divided into four categories: (1) emotional responses, (2) incompatible values, (3) competing interests and (4) ambiguous obligations. The antecedents were (1) ethical sensitivity, (2) negative ethical climate, (3) insufficient authority, (4) unrealistic expectations, (5) poor collaboration and (6) inadequate resources. The consequences were identified as (1) moral residue, (2) loss of identity, (3) professional burnout and (4) poor patient care. CONCLUSIONS: A unified conceptual model of ethical conflict in nursing shed light on the ethical issues nurses might come across in practice. Despite the fact that ethical conflict is inherently negative, we conceptualised this concept as a neutral fact and an opportunity for nursing action. The construct identification provides basis for both the development of practice and the development of staff support and education. RELEVANCE TO CLINICAL PRACTICE: A clearer understanding of such an important facet of nursing practice helps nurses raise awareness of ethical conflict and implement effective coping strategies to improve their well-being and patient care. NO PATIENT OR PUBLIC CONTRIBUTION: This is a review article conducted by the researchers, so there is no patient or public contribution.

Discussion on Conflict and Countermeasures of Beneficial and Non-maleficence Principles in Pediatric Nursing / 中国医学伦理学

In pediatric nursing, the conflict between the principle of beneficial and non-maleficence is a major challenge for nurses. To systematically understand the current situation of the conflict in the nursing practice of pediatric nurses at home and abroad, this paper reviewed four clinical situations where conflict occurs frequently: end-of-life decision-making of critically ill children, physical restraint, the child abuse case report, and new pediatric clinical therapies, and analyzed the factors influencing the conflict of pediatric nurses in China, so as to provide reference for pediatric nurses to cope with the conflict between the principle of beneficial and non-maleficence.

Health teachers' ethical conflict experiences in the COVID-19 situation: a qualitative content analysis.

Background: In the context of the COVID-19 pandemic, health teachers who are responsible for the health of school staff and students are experiencing many ethical conflicts, and research on this is needed. Objective: This study was to investigate and explore the ethical conflicts experienced by health teachers during the COVID-19 pandemic situation. Methods: This was a qualitive study using directed content analysis applied to the four principles of biomedical ethics. Study participants were a total of 26 health teachers in Seoul, South Korea. In-depth individual interviews were conducted with 14 health teachers, and focus group interviews were conducted with the other 12 (2 teams with each 6 persons). Data were collected between May-June 2022, and analyzed using a deductive approach among the qualitative content analysis of Elo and Kyngäs. This study satisfied the four aspects of credibility, transferability, dependability, and confirmability presented by Guba and Lincoln (1989) to secure the reliability of qualitative research. Results: The ethical conflicts related to the four principles of biomedical ethics advocated by Beauchamp and Childress (autonomy, non-maleficence, beneficence, and justice), and the ethical conflicts in which overlap with the two principles of autonomy and non-maleficence, and the ethical conflicts related to miscellaneous matters or relationships, which were not included in the four principles, were investigated as the main 6 categories of ethical conflicts experienced by health teachers. Based on this, 10 generic categories and 17 subcategories were derived. Conclusion: This study could be used as primary data for policy development and intervention research. Such engagements can help identify ethical conflicts faced by health teachers in infectious disease crises, thus improving their ability to cope.

The relationships of ethical climate, physician-nurse collaboration and psychological empowerment with critical care nurses' ethical conflict in China: A structural equation model.

AIMS: To explore the relationships of ethical climate, physician-nurse collaboration and psychological empowerment with ethical conflict in critical care nurses. BACKGROUND: Ethical conflict is a major ethical issue in nursing practice. Little research has been done on the associated factors from both organizational and personal perspectives, especially in China. METHODS: From October 2021 to March 2022, we collected the data from 342 critical care nurses in three tertiary general hospitals in China via questionnaires about four variables (ethical climate, physician-nurse collaboration, psychological empowerment and ethical conflict). Data were analysed using Spearman's correlation and a structural equation model through statistical product and service solutions (SPSS) and analysis of moment structure (AMOS). RESULTS: Critical care nurses' ethical conflict showed a negative correlation with ethical climate (r = -0.351), physician-nurse collaboration (r = -0.347) and psychological empowerment (r = -0.259) (all p < 0.001). Physician-nurse collaboration partially mediated the relationship between ethical climate and ethical conflict. Additionally, physician-nurse collaboration and psychological empowerment served as sequential mediators in the association. CONCLUSIONS: These findings suggested that negative ethical climate can lead to poor physician-nurse collaboration and ultimately ethical conflict. The intermediary role of psychological empowerment and physician-nurse collaboration was also identified. IMPLICATIONS FOR NURSING MANAGEMENT: Nursing managers should use the study as a fundamental basis to evaluate factors that can affect nurses' ethical conflict and develop effective strategies to mitigate this issue, which may help improve nurses' wellbeing and quality of patient care.

Moral Distress Scores of Nurses Working in Intensive Care Units for Adults Using Corley's Scale: A Systematic Review.

BACKGROUND: No systematic review in the literature has analyzed the intensity and frequency of moral distress among ICU nurses. No study seems to have mapped the leading personal and professional characteristics associated with high levels of moral distress. This systematic review aimed to describe the intensity and frequency of moral distress experienced by nurses in ICUs, as assessed by Corley's instruments on moral distress (the Moral Distress Scale and the Moral Distress Scale-Revised). Additionally, this systematic review aimed to summarize the correlates of moral distress. METHODS: A systematic search and review were performed using the following databases: Cumulative Index to Nursing and Allied Health Literature (CINAHL), the National Library of Medicine (MEDLINE/PubMed), and Psychological Abstracts Information Services (PsycINFO). The review methodology followed PRISMA guidelines. The quality assessment of the included studies was conducted using the Newcastle-Ottawa Scale. RESULTS: Findings showed a moderate level of moral distress among nurses working in ICUs. The findings of this systematic review confirm that there are a lot of triggers of moral distress related to patient-level factors, unit/team-level factors, or system-level causes. Beyond the triggers of moral distress, this systematic review showed some correlates of moral distress: those nurses working in ICUs with less work experience and those who are younger, female, and intend to leave their jobs have higher levels of moral distress. This systematic review's findings show a positive correlation between professional autonomy, empowerment, and moral distress scores. Additionally, nurses who feel supported by head nurses report lower moral distress scores. CONCLUSIONS: This review could help better identify which professionals are at a higher risk of experiencing moral distress, allowing the early detection of those at risk of moral distress, and giving the organization some tools to implement preventive strategies.

Ethical Analysis on a Patient with a Chronic Wound Nonunion Refused to be Hospitalized / 中国医学伦理学

This paper introduced a case of ethical conflict between the principle of benefit and the principle of respect in the formulating treatment and nursing plan for patient with chronic wound nonunion by specialist nurses, and used the "structured analysis form of clinical nursing ethics" designed by the Third Affiliated Hospital of Guangzhou Medical University to conduct ethical analysis and ethical decision-making, and solve the clinical nursing ethical problems of complex nursing cases. The practice of the case showed that under the situation of ethical conflict in making nursing treatment plan for patient, the application of structured ethical analysis of clinical nursing is helpful to improve nurses’ ethical decision-making ability and strengthen their ethical thinking. It is suggested to strengthen nurses’ ethical thinking in clinical nursing, continuously improve nurses’ ethical decision-making ability, and cultivate core nursing technology integrating science and humanities, thus to enhance nursing value.

Ethical Conflict and Its Psychological Correlates among Hospital Nurses in the Pandemic: A Cross-Sectional Study within Swiss COVID-19 and Non-COVID-19 Wards.

BACKGROUND: During the Covid-19 pandemic, nurses experienced increased pressure. Consequently, ethical concerns and psychological distress emerged. This study aimed to assess nurses' ethical conflict, resilience and psychological impact, and compare these variables between nurses who worked in Covid-19 wards and nurses who did not. METHODS: Design-Multicentre online survey. Setting-Multi-site public hospital; all nursing staff were invited to participate. The survey included validated tools and a novel instrument to assess ethical conflict. Spearman's rho coefficient was used to assess correlations between ethical conflict and psychological distress, logistic regressions to evaluate relationships between nurses' characteristics and outcome variables, and the Mann-Whitney/t-test to compare groups. RESULTS: 548 questionnaires out of 2039 were returned (275 = Covid-19; 273 = non-Covid-19). We found a low-moderate level of ethical conflict (median = 111.5 [76-152]), which emerged mostly for seeing patients dying alone. A moderate and significant positive correlation emerged between ethical conflict and psychological distress rs (546) = 0.453, p < 0.001. Nurses working in Covid-19-ICUs (OR = 7.18; 95%CI = 3.96-13.01; p < 0.001) and Covid-19 wards (OR = 5.85; 95%CI = 3.56-9.6; p < 0.001) showed higher ethical conflict. Resilience was a protective factor for ethical conflict. CONCLUSIONS: Ethical conflict was significantly linked to psychological distress, while a higher level of resilience was found to be a protective factor. These results can be informative for nursing management in future similar crises.

Psychometric properties of the ethical conflict in nursing questionnaire critical care version among Chinese nurses: a cross-sectional study.

BACKGROUND: Ethical conflicts are common in the critical care setting, and have compromised job satisfaction and nursing care quality. Using reliable and valid instruments to measure the ethical conflict is essential. This study aimed to translate the Ethical Conflict in Nursing Questionnaire - Critical Care Version into Chinese and determine the reliability and validity in the population of Chinese nurses. METHODS: Researchers obtained permission and followed the translation-backward method to develop the Chinese version of the Ethical Conflict in Nursing Questionnaire - Critical Care Version (ECNQ-CCV-C). Relevant psychometric properties were selected according to the Consensus-based standards for the selection of health status measurement instruments checklist. Critical care nurses were recruited from two tertiary public hospitals in Hangzhou, Zhejiang Province, and Kunming, Yunnan Province. Of the 264 nurses we approached, 248 gave their consent and completed the study. RESULTS: The ECNQ-CCV-C achieved Cronbach's alphas 0.902 and McDonald's omega coefficient 0.903. The test-retest reliability was satisfactory within a 2-week interval (intraclass correlation coefficient = 0.757). A unidimensional structure of the ECNQ-CCV-C was determined. Confirmatory factor analysis supported acceptable structure validity. Concurrent validity was confirmed by a moderate relation with a measure for hospital ethical climate (r = - 0.33, p < 0.01). The model structure was invariant across different gender groups, with no floor/ceiling effect. CONCLUSIONS: The ECNQ-CCV-C demonstrated acceptable reliability and validity among Chinese nurses and had great clinical utility in critical care nursing.

Ethical conflict during COVID-19 pandemic: the case of Spanish and Italian intensive care units.

AIM: To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting. BACKGROUND: During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex. SOURCES OF EVIDENCE: Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication. DISCUSSION: The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research. CONCLUSIONS: Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics. IMPLICATIONS FOR NURSING PRACTICE AND POLICY: Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.

Ethical conflicts in nursing: An interview study.

BACKGROUND: A growing body of evidence about nurses' ethical conflicts has been added to nursing science in recent decades, but no research has been done in Estonia. Ethical conflicts are a cultural and context sensitive phenomenon, so the historical, legal, social, economic and political backgrounds and position of nursing have had an impact on ethical conflict experiences. AIM: Describe nurses' experiences of ethical conflicts. METHOD: A qualitative, descriptive study was conducted among nurses (n = 21) in May-October 2018 in Estonia. The data were collected in the form of semi-structured individual interviews and analysed using the inductive content analysis method. ETHICAL CONSIDERATIONS: Due to the sensitive nature of the research topic, only individual interviews were carried out. FINDINGS: Nurses' ethical conflicts were related to situations that violated the rights, safety or well-being of the patient or relatives, caused them suffering, were against their will or threatened nurses' dignity and professionalism through a variety of practices, attitudes and relationships. The insufficiency of patient care and professional collaboration emerged as important sources of nurses' ethical conflicts and were connected to historical and societal factors. CONCLUSIONS: In order to achieve good quality of care, nurses need to have appropriate education and organisational support to carry out ethical daily care. More research is needed to understand the multidimensional cultural and contextual knowledge of ethics and nurses' ethical conflicts.