Int Arch Nurs Health Care ISSN: 2469-5823

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International Archives of Nursing and Health Care

University of Texas at Tyler, Longview University Center, USA

"Work engagement is essential for ethical nursing practice [1]".

Due to the intimate nature of nursing and caring, the ethical perspective of one's nursing is directly related to one's morals-along with one's inner sense of being a nurse. The nurse's ability to be engaged and connected within the work environment is reflected by a greater ethical dedication and reflection on her/his clinical practice.

Notably, the current healthcare environment has a large impact on nurses' levels of work engagement. This is due to many factors within the environment: the personalities of supervisors and peers within the clinical settings, their respective support levels and values, the nature of the patients and their conditions including the resources to care for them, having adequate breaks and relief from stressors within the environment, and one's underlying personal health and mental wellness/illness. All these things and more play into one's sense of engagement. Actually, one's sense of engagement can fluctuate over time.

How can we better assist nurses to maintain their sense of engagement within the clinical environment, delivering high quality care with admirable ethical standards? This is a complex question given our dynamic, multifaceted, and demanding clinical settings.

Ethical issues can easily arise in clinical practice. These ethical problems for nurses can be threefold [2]. First, there can be moral uncertainty (intuition that a moral conflict exists-but the person cannot define it, so it prevents decision making). Second, there are situations where complex situations arise and conflicts of values are present, these are referred to as moral dilemmas. Lastly, situations of moral distress can occur when there are hindrances to performing what is felt to be the best care, yet that care cannot be implemented because of someone or something within the situation.

When referring to ethical issues, clinical decisions are made with the knowledge, attitudes, and resources available at the time. First we need to review the roles we are expecting the nurses to carry out. Do the nurses have the physical, mental, and emotional tools to carry out daily care as the staffing assignments dictate? The quality of the care delivered is so dependent on the time available to provide the care. The intention of assignments is to be appropriate and caring this will assist to ensure the delivery of quality care with the right nursing attitudes and skills. When the environment is proactive, fair, stimulating, and intentional in disseminating nursing assignments (and establishing solid cross-covering for breaks) this provides a wonderful foundation for quality care. It establishes an environment where quality and ethical standards are not threatened or weakened. The shifts that are worked and the conditions in which the care is provided all set the stage for excellent or suboptimal care. However, on some clinical units today such as seen on a busy medical floor, the patients have complicated medical problems, minimal to no support from family or friends, and care dilemmas which can be life threatening. For example, a patient may be deciding if dialysis is going to be an ongoing part of their future care, burdening the limited resources that are already stressed for them. And, can they survive the ‘circular' sickness-wellness cycle of dialysis? Where the benefits only last a few days, then the itching, lethargy, and irritations reoccur? Another example is a sixteen year old patient, an ‘outcast from the community' due to drugs and stealing, may be refusing to have his right leg removed (which is clinically required due to a bullet going through his right femoral artery which feeds his right leg) and he is ‘mad at the world'. Either of these patients may or may not see the depth of the illness, pain, and death which they are experiencing.

The nurses ‘caring' for these patients have difficult situations to address. To minimize the accumulation of similar distresses, nurses need to ensure the provision of down time so that stressful situations do not have cumulative negative effects on their mental wellness/health. Assignments can be rotated to disseminate the high intensity and stressful patients to the various staff members with the intention to limit the exposure to the ‘extreme' stressors. Staff should be well aware of their personal levels of stress, their triggers, their reliefs, and the resources available to assist them with their daily caring. However, this personal awareness is not a usual focus in clinical routines, not highlighted or preempted. Most nurses fall apart before they are even aware of their internal emotional instability. These nurses are at great risk for unethical decision making due to their lack of solid grounding with others and their environment. However, with forethought and preparation, nurses can be ready and willing to discuss any issue that is potentially threatening their personal delivery of high care standards. This should be welcomed, done proactively, and encouraged for each nurse. Strong and caring psychological support personnel should be consistently available and ready to help out with any potential problems. This would be a truly caring environment. This should be a standard of 'care'.

There needs to be informal, yet structured, discussion opportunities for all types of nurses and all shifts to debrief and explore their care provision. A small group of nurses could form a discussion forum to explore what assisted and what also hindered the type of care that was delivered. This type of reflective practice can be rejuvenating and motivating with the right type of supportive moderator leading the discussions. These discussions could be part of the units' expected behaviors not ‘taking too much time', and being judiciously redirected when discussions become negative. This type of experiential learning and processing is irreplaceable for nursing.

Junior staff should have senior level mentors to assist them to acclimate and learn best practice standards. This training should also include a ‘mental wellness focus' which includes many aids such as prayer, breathing exercises, meditation, exercise, friends which will listen and not judge, trouble shooting professional staff, and sound staffing practices, and many others.

Nurses should be taught to anticipate the coming care changes that are developing from research that is underway. Evidence based practice issues, quality decision making choices, and care pathways should be commonly discussed with new ideas being explored to improve the care that is currently being delivered. This is a sound balance for the negativity that is part of the events that have lead up illnesses which can be overcome when providing quality clinical care for the distressed. Research has demonstrated that the stronger the ethical basis of the organization, the less moral distress is reported [3]. Keeping the workplace with a high level of ethical standards and practices is a constant battle; this is to due to organizational constraints, misinformed and over treated patients, and the lack of time and resources [3]. It is likely to best keep the units well-staffed and equipped, and have adequate support services; this may decrease the stress and anxiety the staff feel on a daily basis.

A note should be made about communication. Nursing's communication occurs at various times and on various levels. When this communication is proactive and preventative, quality care consistently results. When the communication is hindered, blocked, insufficient, or inappropriate, bad things happen. The recent efforts toward structured communication (repeat back and clarifying orders) is assisting care communication, however, this method is not always present on clinical units or strictly enforced, which places patients at risk. Ensuring instructions and rationale are provided during patient care can also assist with minimizing misinterpretations and negative reactions to the care that is being provided.

Nursing should lead practice and embrace necessary changes to advance care, not just be passive in the uptake of forced regulated changes. The care that is provided should be higher than ‘acceptable' standards. There would be a sense of confidence and assurance when staff are delivering care that is best practice and individually appropriate for each patient and family needs. Best practice involves the best available evidence, the experience level of the participants involved, and the patient's values and perspectives. This ‘best practice' care would have less errors, less unnecessary costs, less wasted time, more knowledgeable patients, quicker healing, and more satisfied patients. Not surprisingly, the reduction of ethical issues when delivering this type of care would be relieving for all caregivers.

Quality leadership and followership are all a part of today's nursing teams. How our leaders and peers respond to initiatives directly effects the habits and judgment everyone makes over time. When roles are clear, respected, and provide the foundation for high quality, sound care decisions can occur. In this instance, ethical issues will rarely arise. However, when assignments are repeatedly extremely stressful, one's personal sense of wellness and the unit's organization transition into disarray. Caring is compromised. The ethical standards are at risk. Units that are relocating, changing management personnel, and/or are using numerous temporary staff can place the unit at risk for ethical issues to easily arise.

The proximity of nurses' senses of engagement, caring, and fairness play heavily on the ethical and clinical outcomes that they assist to create. In 2016, the ownership of our practice and care delivery is an opportunity to provide excellent nursing. We need to work together to get the conditions right for sound decision making with high ethical standards. Some critical pieces for ‘ingraining the right conditions' include: proactive emotional caring for ourselves, committed respect for patients' values and desires, and ongoing vigilance for threats to the levels of quality and caring within our environments. Together and prepared, we can provide exceptional ethical caring.

References

1. Keyko K (2014) Work engagement in nursing practice: A relational ethics perspective. Nursing Ethics 21: 879-889.
   


2. Falco-Pegueroles A, Liuch-Canut T, Roldan-Merino J, Goberna-Trica J, & Guardia-Olmos J (2015) Ethical conflict in critical care nursing: Correlation between exposure and types. Nursing Ethics 22: 594-607.
   


3. Atabay G, Cangarli BG, Sebnem P (2015) Impact of ethical climate on moral distress revisited: Multidimensional view. Nursing Ethics 22: 103-116.