Critical care nurses, ethical decision-making and stress

Spatial patterning of occupational stress and its related factors in Iranian critical care nurses using a hierarchical Bayesian technique

BACKGROUND: In each community, health problems’ patterns and geographical changes are of prime importance to determine high and low-risk areas. OBJECTIVES: This study aimed to investigate the Spatial patterning of occupational stress and its related factors in Iranian critical care nurses using a hierarchical Bayesian technique METHODS: The current research was a cross-sectional descriptive-analytical study. The data includes the number of critical care unit nurses who show a high stress level based on a questionnaire. We used variables such as age, gender, collaboration status, working time, marital status, clinical experience, education, supervisor support, stress score, and working on holiday days for this study. The survey participants had to be at least 18 years old, a registered nurse, and working in the intensive care unit (ICU). OpenBUGS version 3.2.3 was used to implement the Bayesian hierarchical Poisson model and find partial patterning of occupational stress and its related factors. RESULTS: The final sample size was 17414 nurses. The overall prevalence of occupational stress in ICU nurses was estimated at 70%. The lowest and highest prevalence was 65.8% in the North Khorasan province and 75.2% in Golestan province. Occupational stress had a statistically significant association with collaboration status, but with demographic variables, shift work, supportive supervisor, and working on holidays had no statistically significant association. CONCLUSIONS: According to the findings, it is necessary to eliminate or reduce job stress and increase efficiency in Iranian nurses, encourage teamwork and collaboration as an essential element of a healthy workplace environment.

Predictors of Moral Distress in a US Sample of Critical Care Nurses

BACKGROUND

Moral distress in registered nurses causes decreased job satisfaction, turnover in staffing, burnout, and heightened states of psychological distress. To date, investigation of modifiable factors, such as perceptions of the practice environment and patient safety, among a diverse sample of critical care nurses has been limited.

OBJECTIVE

To explore the relationships among the severity of moral distress, the practice environment, and patient safety in a national sample of critical care nurses.

METHODS

Critical care nurses experienced in working with adults (> 1 year of intensive care unit experience) and who were subscribers to the American Association of Critical-Care Nurses' e-mail listserv and social media sites anonymously participated in this descriptive study. Participants completed a demographic questionnaire, the Moral Distress Scale-Revised, and the Practice Environment Scale of the Nursing Work Index. Descriptive statistics, bivariate correlation coefficients, and a hierarchical regression analysis were used to describe the sample characteristics and to assess relationships among the study variables.

RESULTS

Of a national sample of 328 critical care nurses, 56% had less than 20 years of experience as a registered nurse. Moral distress was modestly associated with negative perceptions of the practice environment and patient safety. Job satisfaction, practice environment, and the participant's age were statistically significant predictors of moral distress in this sample.

CONCLUSIONS

Modifications of organizational factors such as the development of healthy work environments that promote collegial relationships could reduce moral distress among critical care nurses.

Effects of Stress on Critical Care Nurses: A National Cross-Sectional Study

Background:

Health care is a demanding field, with a high level of responsibility and exposure to emotional and physical danger. High levels of stress may result in depression, anxiety, burnout syndrome, and in extreme cases, post-traumatic stress disorder. The aim of this study was to determine which personal, professional, and organizational variables are associated with greater perceived stress among critical care nurses for purposes of developing integrative solutions to decrease stress in the future.

Methods:

We conducted a correlation research survey using a cross-sectional design and an in-person survey method. The questionnaire consisted of 2 parts: (1) socioeconomic, professional, and institutional variables and (2) work stressors. Surveys were conducted between January 1, 2011, and December 1, 2015. Multistage cluster random sampling was utilized for data collection. Inclusion criteria were (1) age ≥18 years, (2) registered nurse, (3) works in the intensive care unit (ICU), and (4) willing and able to complete the survey.

Results:

We surveyed 21 767 ICU nurses in Iran and found that male sex, lower levels of peer collaboration, working with a supervisor in the unit, nurse–patient ratios, and working in a surgical ICU were positively associated with greater stress levels. Increasing age and married status were negatively associated with stress. Intensive care unit type (semi-closed vs open), ICU bed number, shift time, working on holidays, education level, and demographic factors including body mass index, and number of children were not significantly associated with stress levels.

Conclusion:

As the largest study of its kind, these findings support those found in various European, North, and South American studies. Efforts to decrease workplace stress of ICU nurses by focusing on facilitating peer collaboration, improving resource availability, and staffing ratios are likely to show the greatest impact on stress levels.

Stress and its Impact on the Neurocognitive Performance of Australian Nurses

Nurses function inside a particularly stressful occupation that requires the provision of continuous care to individuals who are often in great need. Stress has been shown to impair performance and specifically shown to impair nursing quality. However, we do not yet know how stress influences the cognitive performance of nurses, and hence, the present study investigated the associations between stress and cognitive performance in nurses using electroencephalography and administered cognitive assessments. Thirty-six nurses (34 women) of mean age 37.77 ± 11.40 years were recruited. Stress was examined using the Lifestyle Appraisal Questionnaire. Broad spectrum electroencephalogram activity at positions Fp1, Fp2, C3 and C4 was recorded for a 5-min baseline and active phase to physiologically assess cognitive performance. Additionally, the Mini-Mental State Exam and Cognistat were also used to measure cognitive performance. Assessed cognitive performance was not associated to stress, however, lifestyle factors, as well as a number of the examined cognitive electroencephalographic variables including changes in theta, alpha activity and gamma reactivity were. Definitively determining how stress affects the cognitive performance of nurses requires additional research; the present study forms a foundation from which future research can further expand the examination of stress exposure in nurses. Copyright © 2016 John Wiley & Sons, Ltd.

Differences in Moral Judgment Between Nursing Students and Qualified Nurses

This longitudinal study examined how nursing students' moral judgment changes after they become qualified nurses working in a hospital environment. The sample used was a group of 80 nursing students attending a university in Suwon, Korea, between 2001 and 2003. By using a Korean version of the Judgment About Nursing Decisions questionnaire, an instrument used in nursing care research, moral judgment scores based on Ketefian's six nursing dilemmas were determined. The results were as follows: (1) the qualified nurses had significantly higher idealistic moral judgment scores than the nursing students; (2) the qualified nurses showed significantly higher realistic moral judgment scores than the nursing students; and (3) when comparing idealistic and realistic moral judgment scores, both the qualified nurses and the nursing students had higher scores for idealistic moral judgment. Further study is recommended to examine changes in moral judgment.

Perceptions of Conscience in Relation To Stress of Conscience

Every day situations arising in health care contain ethical issues influencing care providers' conscience. How and to what extent conscience is influenced may differ according to how conscience is perceived. This study aimed to explore the relationship between perceptions of conscience and stress of conscience among care providers working in municipal housing for elderly people. A total of 166 care providers were approached, of which 146 (50 registered nurses and 96 nurses' aides/enrolled nurses) completed a questionnaire containing the Perceptions of Conscience Questionnaire and the Stress of Conscience Questionnaire. A multivariate canonical correlation analysis was conducted. The first two functions emerging from the analysis themselves explained a noteworthy amount of the shared variance (25.6% and 17.8%). These two dimensions of the relationship were interpreted either as having to deaden one's conscience relating to external demands in order to be able to collaborate with coworkers, or as having to deaden one's conscience relating to internal demands in order to uphold one's identity as a `good' health care professional.

Development and Initial Validation of the Stress of Conscience Questionnaire

Stress in health care is affected by moral factors. When people are prevented from doing ‘good’ they may feel that they have not done what they ought to or that they have erred, thus giving rise to a troubled conscience. Empirical studies show that health care personnel sometimes refer to conscience when talking about being in ethically difficult everyday care situations. This study aimed to construct and validate the Stress of Conscience Questionnaire (SCQ), a nine-item instrument for assessing stressful situations and the degree to which they trouble the conscience. The items were based on situations previously documented as causing negative stress for health care workers. Content and face validity were established by expert panels and pilot studies that selected relevant items and modified or excluded ambiguous ones. A convenience sample of 444 health care personnel indicated that the SCQ had acceptable validity and internal consistency (Cronbach’s alpha exceeded 0.83 for the overall scale). Explorative factor analysis identified and labelled two factors: ‘internal demands’ and ‘external demands and restrictions’. The findings suggest that the SCQ is a concise and practical instrument for use in various health care contexts.

A Qualitative Analysis of Ethical Problems Experienced by Physicians and Nurses in Intensive Care Units in Turkey

In this qualitative study, we aimed to identify and compare the ethical problems perceived by physicians and nurses in intensive care units at Baskent University hospitals in Turkey. A total of 21 physicians and 22 nurses were asked to describe ethical problems that they frequently encounter in their practice. The data were analyzed using an interactive model. The core problem for both physicians and nurses was end-of-life decisions (first level). In this category, physicians were most frequently concerned with euthanasia while nurses were more concerned with do-not-resuscitate orders (second level). At the third level, we saw that almost all of the participants’ responses related to negative perceptions about euthanasia. Communication and hierarchical problems were the second most reported main category. Nurses were more likely to cite problems with hierarchy than physicians. At the third level, a large percentage of nurses described communication problems with authority and hierarchical problems with physicians. In the same category, physicians were most often concerned with communication problems with patients’ relatives. The ethical problems were reported at different frequencies by physicians and nurses. We asked the participants about ethical decision-making styles. The results show that nurses and physicians do not follow a systematic pattern of ethical decision making.

Nurses’ Ethical Perceptions of Health Care and of Medical Clinical Research: an audit in a French university teaching hospital

Very few data exist in France on: (1) nurses’ knowledge and behaviour concerning ethical decisions in clinical practice; and (2) their knowledge of ethical rules in clinical research. This questionnaire-based audit tried mainly to assess these questions in a large French university teaching hospital. Of the 257 questionnaires distributed to nurses in 23 clinical units of the hospital, 206 were returned (80% response rate). When responding to the vignette describing a clinical situation requiring an ethical decision to be made, most nurses acted as the patient’s advocate although they have had no formal training in ethics. Indeed, 66% of nurses responding considered that the patients themselves should be the primary decision makers in situations that relate to their health and medical care. For children or comatose patients, the decision should be left to the relatives according to 72% of the responses. The results indicated that the role of health care professionals in ethical decisions made for a given patient should be marginal. Nurses’ knowledge concerning research protocols, particularly their ethical requirements and consequences, is poor at present and information from and communication with doctors should be improved.

Evaluation of Mental Workload among ICU Ward's Nurses

Background: High level of workload has been identified among stressors of nurses in intensive care units (ICUs). The present study investigated nursing workload and identified its influencing perfor­mance obstacles in ICUs.

Methods: This cross-sectional study was conducted, in 2013, on 81 nurses working in ICUs in Imam Khomeini Hospital in Tehran, Iran. NASA-TLX was applied for assessment of workload. Moreover, ICUs Performance Obstacles Questionnaire was used to identify performance obstacles associated with ICU nursing.

Results: Physical demand (mean=84.17) was perceived as the most important dimensions of workload by nurses. The most critical performance obstacles affecting workload included: difficulty in finding a place to sit down, hectic workplace, disorganized workplace, poor-conditioned equipment, waiting for using a piece of equipment, spending much time seeking for supplies in the central stock, poor quality of medical materials, delay in getting medications, unpredicted problems, disorganized central stock, outpatient surgery, spending much time dealing with family needs, late, inadequate, and useless help from nurse assistants, and ineffective morning rounds (P-value<0.05).

Conclusion: Various performance obstacles are correlated with nurses' workload, affirms the significance of nursing work system characteristics. Interventions are recommended based on the results of this study in the work settings of nurses in ICUs.

Nurse-physician collaboration and associations with perceived autonomy in Cypriot critical care nurses

BACKGROUND AND AIMS

Increased nurse-physician collaboration is a factor in improved patient outcomes. Limited autonomy of nurses has been proposed as a barrier to collaboration. This study aims to explore nurse-physician collaboration and potential associations with nurses' autonomy and pertinent nurses' characteristics in adult intensive care units (ICUs) in Cyprus.

DESIGN AND METHODS

Descriptive correlational study with sampling of the entire adult ICU nurses' population in Cyprus (five ICUs in four public hospitals, n = 163, response rate 88·58%). Nurse-physician collaboration was assessed by the Collaboration and Satisfaction About Care Decisions Scale (CSACD), and autonomy by the Varjus et al. scale.

RESULTS

The average CSACD score was 36·36 ± 13·30 (range: 7-70), implying low levels of collaboration and satisfaction with care decisions. Male participants reported significantly lower CSACD scores (t = 2·056, p = 0·04). CSACD correlated positively with years of ICU nursing experience (r = 0·332, p < 0·0001) and professional satisfaction (r = 0·455, p < 0·0001). The mean autonomy score was 76·15 ± 16·84 (range: 18-108). Higher degree of perceived collaboration (CSACD scores) associated with higher autonomy scores (r = 0·508, p <0·0001).

CONCLUSIONS

Our findings imply low levels of nurse-physician collaboration and satisfaction with care decisions and moderate levels of autonomy in ICU nurses in Cyprus.

RELEVANCE TO CLINICAL PRACTICE

The results provide insight into the association between nurse-physician collaboration and nurses' autonomy and the correlating factors.

Stressors in intensive care units in Syria: patients' perceptions

The purpose of this cross-sectional study was to identify the stressors and the level of stress as perceived by hospitalised Syrian patients of intensive care units (ICUs). A convenience sample of 150 Syrians who were hospitalised in ICUs located in the Syrian capital, Damascus, were chosen as study participants and were interviewed using a structured interview guide of the Intensive Care Units Environmental Stressors Scale (ICUESS). The findings revealed that physical stressors were perceived as the most stressful ones, whereas psychological stressors were the least stressful. These findings are congruent with the majority of similarly available regional and international literature. It was also statistically noticed that participants with a higher level of education and income were more sensitive in perceiving the stressors than those who had a lower level of education and income. The findings suggested that nurses must utilise effective measures in ICUs to relieve patients' pain and provide a humane ICU environment and atmosphere in which rest is enabled. In conclusion, decreasing the stress level has a positive impact on patients' health outcomes, where adequate attention to patients' physical and psychological domains should equally be considered.

Prevalence and relationship between burnout, job satisfaction, stress, and clinical manifestations in Spanish critical care nurses

Stress, burnout, and job satisfaction have become increasingly important in nursing environments over the last 20 years. For critical care nurses, the work environment is extremely stressful, even for the best-prepared professional. The aims of this study were to measure the prevalence of burnout syndrome, job satisfaction, job stress, and clinical manifestations of stress and to demonstrate the relationship between these variables among Spanish critical care nurses with a convenience sample of 74. Results showed a moderate frequency of nursing stress, high frequency of emotional exhaustion, and negative evaluation of career accompanied by moderate development of negative attitudes toward patients (depersonalization). Other findings are also presented.

What factors affect nursing retention in the acute care setting?

Moral distress and professional stress affect the lives of acute care nurses everyday. The impact of these stressors may be causing nurses to leave the acute care setting. This paper will outline the findings from a descriptive study of acute care nurses in Northeast Florida. The research was conducted in an effort to highlight some of the critical factors that impact nurses in the acute care setting and affect their intent to stay at an institution. The concepts of moral distress and professional stress in relation to nursing retention are highlighted and some strategies for lessening of these stressors are proposed. The study was correlational and conducted among 234 nurses in an institutional setting. The study included an online survey based on established Moral Distress and Professional Stress tools. In addition, a qualitative section was included to explore the nurses’ experiences of stressful inpatient situations. The results of this study demonstrated that when combined, both professional stress and moral distress items were predictive of the nurses’ intent to stay at the institution ( p <.001).

Professional and cultural conflicts for intensive care nurses

AIM

This paper is a report of a study exploring intensive care nurses' experiences of conflicts related to practical situations when they encounter culturally diverse families of critically ill patients.

BACKGROUND

Conflicts can arise in critical care settings as a result of differing cultural and professional values. Nurses and families with diverse cultural backgrounds bring beliefs and understandings to the care situation that can have an impact on the care process. Such families are challenged in their efforts to maintain traditions, while some nurses are not sufficiently culturally aware. A limited number of studies have focused on such conflicts.

METHOD

Sixteen critical care nurses took part in multistage focus group interviews conducted from October 2005 to June 2006. The data were analysed using qualitative content analysis.

FINDINGS

The main theme, 'conflict between professional nursing practice and family cultural traditions', was based on three pairs of conflicting themes: 'culturally based need to participate actively in the care vs. nurses' professional perceptions of themselves as total care providers'; 'nurses' professional obligation to provide comprehensible information vs. culturally based communication difficulties and responses to illness'; and 'families' needs for cultural norms and self-determination vs. nurses' professional responsibility for the clinical environment'. In addition, each pair of themes contained several sub-themes.

CONCLUSION

Nurses need to negotiate with culturally diverse family members to address conflicts. In their encounters with such families, they should establish a balance between ethnocentricity and cultural sensitivity. An implication for practice is to increase nurses' competence in assessment of diversity.

Ethical problems observed by student nurses

This descriptive study was conducted to determine nursing students' observation of ethical problems encountered in their clinical practice. Data were collected through a questionnaire from 153 volunteer nursing students at a university-based nursing school in Ankara, Turkey. The students reported that some patients are either physically or psychologically mistreated by doctors and nurses; they were not given appropriate information; they were subjected to discrimination according to their socio-economic situation; and their privacy was ignored. The findings reveal that nurses' own unethical behaviors contribute to a rise in ethical problems. It is argued that nurses should internalize their professional and ethical roles in order to provide safe and ethical care and be good role models for students.

Nursing Advocacy in Procedural Pain Care

In nursing, the concept of advocacy is often understood in terms of reactive or proactive action aimed at protecting patients' legal or moral rights. However, advocacy activities have not often been researched in the context of everyday clinical nursing practice, at least from patients' point of view. This study investigated the implementation of nursing advocacy in the context of procedural pain care from the perspectives of both patients and nurses. The cross-sectional study was conducted on a cluster sample of surgical otolaryngology patients ( n = 405) and nurses ( n = 118) from 12 hospital units in Finland. The data were obtained using an instrument specially designed for this purpose, and analysed statistically by descriptive and non-parametric methods. According to the results, patients and nurses have slightly different views about which dimensions of advocacy are implemented in procedural pain care. It seems that advocacy acts are chosen and implemented rather haphazardly, depending partly on how active patients are in expressing their wishes and interests and partly on nurses' empowerment.

Decision support in multi-professional communication

This paper explores the role of clinical decision support systems (CDSS) in facilitating communication between physicians, nurses, patients and family members. Thirty-three critical care unit nurses and physicians were interviewed regarding the APACHE III CDSS. This qualitative, descriptive study suggests that registered nurses and physicians are primarily motivated to use CDSS when this technology allows them to forecast the potential outcomes of decisions prior to actually making those decisions. These forecasts are used to advocate for care decisions with other disciplines, patients and their family members. Implications for professional practice and recommendations for future research are described.

Work-home interference among nurses: reciprocal relationships with job demands and health

AIMS

This paper is a report of a study with three aims: (i) to investigate whether emotional, quantitative and physical demands have a causal, negative impact on nurses' health; (ii) to examine whether work-home interference can explain this effect, by playing a mediating role; and (iii) to test the so-called loss spiral hypothesis claiming that nurses' health problems lead to even higher job demands and more work-home interference over time.

BACKGROUND

While many scholars have thought in terms of the stressor-->work-home interference-->strain model, the validity of a model that includes opposite pathways needs to be tested.

METHOD

A questionnaire was completed twice, with a 1-year time interval by 753 (63.4%) Registered Nurses working in hospitals, 183 (15.4%) working in nursing homes, and 251 (21.1%) working in home care institutions. The first measurement took place between October 2002 and June 2003.

FINDINGS

Our findings strongly support the idea of cross-lagged, reciprocal relationships between job demands and general health over time. The reciprocal model with work-home interference as an intervening variable (including reciprocal relationships between job demands, work-home interference and general health) showed a good fit to the data, and proved to be superior to both the causality and reversed causation models.

CONCLUSION

The higher nurses' job demands, the higher is their level of work-home interference and the more likely is a general health deterioration over time, in turn giving rise to higher job demands and work-home interference, which may even aggravate the nurses' general health, and so on.

Respecting the wishes of patients in intensive care units

This study examined why intensive care unit (ICU) nurses experience difficulties in respecting the wishes of patients in end-of-life care in Japan. A questionnaire survey was conducted with ICU nurses working in Japanese university hospitals. The content of their narratives was analyzed concerning the reasons why the nurses believed that patients' wishes were not respected. The most commonly stated reason was that patients' wishes were impossible to realize, followed by the fact that decision making was performed by others, regardless of whether the patients' wishes were known, if the death was sudden, and time constraints. Many nurses wanted to respect the wishes of dying patients, but they questioned how patients die in ICUs and were therefore faced with ethical dilemmas. However, at the same time, many of the nurses realized that respecting patients' wishes about end-of-life care in an ICU would be difficult and that being unable to respect these wishes would often be unavoidable. The results thus suggest that there has been insufficient discussion about respecting the wishes of patients undergoing intensive care.

The relationship between moral distress and perception of futile care in the critical care unit

PURPOSE

Study the relationship between moral distress (MD) and futile care in the critical care unit (CCU).

SUBJECTS AND METHODS

A cross-sectional survey consisting of 38 clinical situations associated with MD related to 6 categories: physician practice, nursing practice, institutional factors, futile care, deception and euthanasia was distributed to 100 nurses at a single CCU. The intensity and frequency of MD were scored with Likert scale: 0-lowest and 6-highest.

RESULTS

The survey was completed by 44 (44%) nurses. Median age was 33 years, 80% females. Median intensity of MD was high for the six categories and had no relationship with age, time in CCU or nursing practice. The encounter frequency of MD for futile care was the highest and was significantly related to age >33 years (p=0.03), time in CCU >4 years (p=0.04) and nursing practice >7 years (p=0.01).

CONCLUSION

MD associated with clinical situations representing futile care increased with time in CCU. Future interventions are required to minimize the exposure to futile care situations and develop mechanisms to mitigate the effects of MD in the CCU.

Workload and patient safety among critical care nurses

Several dimensions of workload experienced by nurses working in ICUs are described in this article, including the physical workload related to patient handling. The effects of workload on various outcomes, such as the health, safety, and quality of working life of nurses, and the safety of care provided by ICU nurses are discussed. A systemic approach to the assessment of workload is proposed that is aimed at identifying the work system factors that contribute to the different facets of workload and the interdependencies among the various dimensions of workload.

Jordanian patients’ perception of stressors in critical care units: A questionnaire survey

BACKGROUND

Critical care units' CCUs environment has been regarded as a leading stressor because of the complex nature of patient's health problems that require an extensive use of very sophisticated technology. Multiple and complex care predominates in CCUs have been described by patients to be stressful and emotionally demanding.

RATIONALE

Number of CCUs in Jordan has been increasing and so does the advanced technology, which calls for adaptability in dealing with unit stressors as they affect patient recovery and rehabilitation.

OBJECTIVES

To identify the principal physical and psychological stressors as perceived by Jordanian patients in CCUs and to examine the effects of selected patients' characteristics on their perception of stressors.

METHODS

In this cross-sectional study, data was collected from 165 patients, 2-3 days after being discharged from CCUs in two Jordanian governmental hospitals. A structured interview guide including the Intensive Care Unit Environmental Stressor Scale was used.

RESULTS

Having tubes in nose or mouth, being in pain, not able to sleep and hearing the buzzers and alarms from the machinery, being thirsty, and not being in control of your-self were considered by patients as the main stressors. Psychological stressors were the least stressful items identified by patients. Marital status, educational level, age, and income were the most significant characteristics which affected patients' perception of stressors.

CONCLUSIONS

The findings suggest that single and older patients with low income and low education experience more difficulties than their counterparts. Nurses must utilize more effective communication techniques and interventions to relieve patients' pain, and provide an atmosphere in which rest is possible, with less light, noise, and the fewest possible interruptions. Although the results of this study indicate the need to provide the best possible physical care, it is equally important to give adequate attention to patients' and families' psychological aspects.

Pilot exploration of the association between self-esteem and professional satisfaction in Hellenic Hospital nurses

AIM

To explore potential associations between nurses' self-esteem and professional satisfaction.

BACKGROUND

Professional burnout and moderate job satisfaction have been reported consistently among nurses. However, potential associations of the above elements with personality characteristics have not been adequately addressed.

METHODS

A random sample of 154 adult healthcare nurses completed the Maslach Burnout Inventory, the Berger's Scale and the Index of Work Satisfaction. Associations and comparisons across different settings and background variables were explored.

RESULTS

Moderate to positive levels of self-acceptance (mean Likert rating: 3.95 +/- 0.51) and acceptance-of-others (mean Likert rating: 3.7 +/- 0.43) and low to moderate levels of professional satisfaction (mean Likert rating: 3.69 +/- 0.63) were observed. Positive correlations were detected between professional satisfaction and self-esteem indices (r = 0.249-0.313, P < or = 0.008). A mediating effect of burnout was implied.

CONCLUSIONS

A potential interaction between personality and professional attitudes of Hellenic Hospital nurses was observed. The present study is limited within the correlational frame. Further study is needed to investigate a potential causal relationship between self-esteem indices and professional satisfaction, in order to inform nursing retention and support policies.

Measuring moral distress in pharmacy and clinical practice

This article presents the development, validation and application of an instrument to measure everyday moral distress in different health care settings. The concept of moral distress has been discussed and developed over 20 years. A few instruments have been developed to measure it, predominantly in nursing. The instrument presented here consists of two factors: level of moral distress, and tolerance/openness towards moral dilemmas. It was tested in four medical departments and three pharmacies, where 259 staff members completed a questionnaire. The two factors were found to be reliable. Differences in levels of moral distress were found between pharmacies and clinical departments, and between the youngest and oldest age groups; departmental staff and the youngest group experienced higher levels of moral distress. Departments reported less tolerance/openness towards moral dilemmas than pharmacies. The instrument needs to be tested further, but its strengths are the focus on everyday ethical dilemmas and its usefulness in different health care settings.

Symptoms suffered by life-limited children that cause anxiety to UK children’s hospice staff

BACKGROUND

Very little is published about the symptom profile of children with life-limiting illnesses other than cancer.

METHOD

A postal questionnaire was sent to children's hospice staff who were asked to identify symptoms experienced by life-limited children which caused them anxiety.

RESULTS

Staff in 23 hospices were sent questionnaires. Twenty-eight questionnaires were returned from 10 doctors and 18 nurses. Just under half of the hospices contacted were represented. The staff were very experienced but had significant anxieties about treating some of their patients.

AIMS

This study aimed to identify the symptoms which cause anxiety to staff working in children's hospices. More than 70% of all staff groups felt that identifying the symptom correctly caused more anxiety than treating identified symptoms. For doctors the top five symptom problems were, seizure control, spasms, pain assessment, unidentified distress and vomiting. For nurses the main concerns were the non-verbal child in distress, psychiatric or psychological problems, assessing pain, seizures, pain management, vomiting.

CONCLUSIONS

Doctors and nurses perceive seizures, pain management, and vomiting as the most troublesome symptoms for children with life-limiting conditions. Further research is needed into symptom management in this area.

Burnout contagion among intensive care nurses

AIM

This paper reports a study investigating whether burnout is contagious.

BACKGROUND

Burnout has been recognized as a problem in intensive care units for a long time. Previous research has focused primarily on its organizational antecedents, such as excessive workload or high patient care demands, time pressure and intensive use of sophisticated technology. The present study took a totally different perspective by hypothesizing that--in intensive care units--burnout is communicated from one nurse to another.

METHODS

A questionnaire on work and well-being was completed by 1849 intensive care unit nurses working in one of 80 intensive care units in 12 different European countries in 1994. The results are being reported now because they formed part of a larger study that was only finally analysed recently. The questionnaire was translated from English to the language of each of these countries, and then back-translated to English. Respondents indicated the prevalence of burnout among their colleagues, and completed scales to assess working conditions and job burnout.

RESULTS

Analysis of variance indicated that the between-unit variance on a measure of perceived burnout complaints among colleagues was statistically significant and substantially larger than the within-unit variance. This implies that there is considerable agreement (consensus) within intensive care units regarding the prevalence of burnout. In addition, the results of multilevel analyses showed that burnout complaints among colleagues in intensive care units made a statistically significant and unique contribution to explaining variance in individual nurses' and whole units' experiences of burnout, i.e. emotional exhaustion, depersonalization and reduced personal accomplishment. Moreover, for both emotional exhaustion and depersonalization, perceived burnout complaints among colleagues was the most important predictor of burnout at the individual and unit levels, even after controlling for the impact of well-known organizational stressors as conceptualized in the demand-control model.

CONCLUSION

Burnout is contagious: it may cross over from one nurse to another.

A framework for ethical decision making in neonatal intensive care

Intensive care for neonates with high risks of severe impairment and the possibility of a prolonged dying process represents a frequent ethical issue in neonatal units. The aim of this paper is to present a framework for structured decision making that has been developed in a neonatal intensive care unit and to demonstrate its impact on the healthcare team and on survival of critically ill neonates. This framework attempts to integrate the best interests of the infants and their parents, the possibilities of high-tech neonatal intensive care interventions, and the perspective of the nurses and doctors. An external evaluation of 84 sessions over 3 y revealed a beneficial effect on the quality of the decision-making process itself and on the quality of the teamwork in the unit. Survival time was shorter (median 2 d, interquartile range 1-7 d) in 26 infants that died after structured decision making compared with 26 controls matched for gestational age, malformation and intracranial haemorrhage (median 7 d, interquartile range 4-15 d).

CONCLUSION

The introduction of this framework for structured decision making involving doctors and nurses improved the quality of the teamwork. It shortened futile intensive care, and thereby suffering for both infants and parents.

Nursing advocacy—a review of the empirical research 1990–2003

This paper provides an overview of the empirical research literature on nursing advocacy. It offers a description of the contexts, methods and issues of validity and reliability used in studies of nursing advocacy, as well as advocacy definitions, activities and consequences as results of those studies. The review focuses on empirical articles retrieved from the CINAHL and MEDLINE databases published between 1990 and 2003. It draws attention to complexity the concept of advocacy, difficulties in operationalisation, and concentration on reactive advocacy from nurses' perspective. There is a lack of research on patients' perspectives of nursing advocacy in general hospital settings.

Practice and clinical decision-making autonomy among Hellenic critical care nurses

BACKGROUND

Nursing autonomy has been associated with better patient-outcomes; therefore, it is a priority for critical care nursing management. Low authority has been a persistent complaint of Hellenic intensive care unit nurses; however, issues of nursing autonomy have not been previously addressed empirically in Hellas.

PURPOSE

To investigate: (1) the perceived contribution to clinical decision-making, (2) the degree of autonomy in technical tasks, and (3) factors related to practice autonomy in critical care nurses in Hellas. Additionally, because of the lack of sufficient tools, this study also aimed to construct and to validate a new tool for assessing practice and clinical decision-making autonomy among Hellenic intensive care unit nurses.

MATERIALS AND METHODS

A Hellenic intensive care nursing autonomy scale, focused on technical aspects of care, was developed through literature review, a panel of experts and a pilot study in a random sample of 120 respondents. Items were refined by factor analysis, which revealed three major conceptual categories of autonomy: (1) basic technical, (2) advanced technical, and (3) clinical decision. Hellenic intensive care nursing autonomy (Likert 4, range: 38-152), was distributed to all nurses employed in intensive care units in Hellas (n = 807; attrition: 27%). Comparisons, correlation and multivariate regression were employed.

RESULTS

The Hellenic intensive care nursing autonomy scale exhibited appropriate reliability (Cronbach's alpha = 0.86) and validity properties. Autonomy scores were moderate (mean: 105.24 +/- 9.58). Highest autonomy was attributed to basic technical tasks, followed by advanced technical tasks and decision-making. Male gender and higher education were predictors of higher overall, advanced technical and decision-making autonomy (P = 0.01). Bachelor degree graduates scored higher in decisional autonomy (P = 0.03). Intensive care unit experience and type of intensive care unit were also important determinants of decisional autonomy (P = 0.02).

CONCLUSIONS

The results revealed moderate autonomy in technical tasks and low decisional autonomy among Hellenic intensive care unit nurses. Factors related to the educational preparation of nurses, gender issues and institutional characteristics might hinder intensive care unit nurses' autonomy in Hellas.

Critical Care Nurses’ Perceptions of Futile Care and Its Effect on Burnout

• Background Nurses’ perceptions of futile care may lead to emotional exhaustion.

• Objectives To determine the relationship between critical care nurses’ perceptions of futile care and its effect on burnout.

• Methods A descriptive survey design was used with 60 critical care nurses who worked full-time and had a minimum of 1 year of critical care experience at the 2 participating hospitals (350–470 beds). Subjects completed a survey on demographics, the Moral Distress Scale, and the Maslach Burnout Inventory. Six research questions were tested. The results of the following question are presented: Is there a relationship between frequency of moral distress situations involving futile care and emotional exhaustion?

• Results A Pearson product moment correlational analysis indicated a significant positive correlation between the score on the emotional exhaustion subscale of the Maslach Burnout Inventory and the score on the frequency subscale of the Moral Distress Scale. Moral distress accounted for 10% of the variance in emotional exhaustion. Demographic variables of age, education, religion, and rotation between the critical care units were significantly related to the major variables.

• Conclusions In critical care nurses, the frequency of moral distress situations that are perceived as futile or nonbeneficial to their patients has a significant relationship to the experience of emotional exhaustion, a main component of burnout.

Decision making in Greek and English registered nurses in coronary care units

Clinical decision-making is an integral component of the role of the professional nurse. The aim of the study was to identify the quality of decision making of Greek and English coronary care nurses during the acute and recovery phases post-myocardial infarction (MI), and determine factors that best predict clinical decision-making in these two discrete groups of nurses. By identifying best practice from standard textbooks and expert practitioners, Clinical Decision-Making cards were developed and employed to explore nurse decision-making. A questionnaire (influencing factor questionnaire-IFQ) was also administered to determine which factors predicted quality nurse decision-making in the acute and recovery phase of post-MI patient care. The results showed that nurses in England made better quality clinical decisions in the recovery phase of MI than the Greek counterparts (p<0.001). Variables were identified which best-predicted decision-making. Interestingly, the main finding of this study was that English nurses had greater autonomy in the recovery phase and therefore made more clinical decisions concerning the patient psychosocial recovery than Greek nurses. Nurses perceived clinical experience as the strongest factor influencing decision-making.

Autonomy among intensive care nurses in Finland

The purpose of this study was to describe Finnish ICU nurses' (n=172) experiences of autonomy in their work. The research was carried out as part of a project concerned with empowerment in intensive care nursing. Viewed from a psychological perspective, empowerment is understood as referring to the ability to make goal-directed decisions and to take action towards meeting the goals set out. Autonomy, then, is seen as part of empowerment. The data were collected with a structured questionnaire specially designed for this study. The random sample was drawn from 31 Finnish adult intensive care units. The respondents were registered nurses working in eight adult intensive care units. The data were analysed using statistical methods. Autonomy was defined as being composed of three bases: knowledge base (independence, right and responsibility in decision-making), action base (independence, right and responsibility in actions) and value base (independence, right and responsibility in values). The majority of the respondents felt they had more autonomy in decision-making and actions concerning patient care than in decision-making and actions concerning the intensive care unit as a whole. Autonomy usually increased with work experience. Work will be continued to study the autonomy of nurses in different health care organisations in Finland.

Critical incident: reflection on the process of terminal weaning

The article uses critical incident analysis to reflect on the process of terminal weaning. Terminal weaning is defined in the context of withdrawing ventilatory support when the expected outcome is the patient's death. Basic ethical concepts are identified, and the role of the nurse in ethical decision making is discussed in relation to the associated professional and legal issues. Conflict exists between professional and legal accountability in relation to advocacy. Caution is advised with regard to nurses becoming involved in the decision to terminally wean, and its practice.