Exploring the Challenges Encountered and Strategies Employed by Nurses when Confronted with Moral Decisions: Implication on Moral Competence
Roselyn M. Butalid
College of Health Sciences, Mindanao State University-Iligan Institute of Technology, Tibanga, Iligan City, 9200 Philippines
Corresponding Author’s Email: roselyn.butalid@g.msuiit.edu.ph
ABSTRACT
Background: The public perceived negative attitudes and poor performance by some nurses, implying low moral competence levels. To determine how nurses handle moral issues in nursing practice, this study explored the challenges encountered and strategies employed by nurses when confronted with moral decisions. Methods: This study employed a qualitative research design utilizing in-depth interviews conducted by twenty nurse informants from hospitals in Iligan City, Philippines, recruited through a purposive sampling technique. A researcher-made interview guide with open-ended questions was utilized. The interviews were recorded, transcribed, and thematically analyzed. Results: The emergent themes are “predicaments toward patient and family issues” with two sub-themes (patient/family non- conforming decisions and dealing with emotionally burdened family members), “recognition of own weaknesses and shortcomings” with four sub-themes (infrequent performance of emotional care, insufficient provision of comfort, interference with the patient’s privacy, and delays in care due to prioritization), and “conflict with superiors”. Several strategies were employed to effectively address the moral challenges encountered. Conclusion: Moral competence is inherent in nurses, as they exhibit moral judgment and skills in overcoming the moral challenges encountered. However, there are moral issues beyond control in patient care. Therefore, hospital administrators may conduct a program to enhance the nurses’ competence to handle moral challenges and prevent moral distress, which will improve nursing practice.
Keywords: Moral Competence; Moral Challenges; Nurses; Philippines
INTRODUCTION
Moral competence is the capacity to make moral decisions and judgments and take actions following deep-rooted principles (Haghighat, Borhani, & Ranjbar, 2020). It enables surviving problems in the work environment and managing conflicts by applying inner moral principles rather than abiding by society’s expectations (Bronikowska et al., 2019). Moral competence also refers to altruistic behavior and the ability to respect the moral perspectives of others (Ma, 2012; Johnstone, 2015). Nurses need moral competence in the delivery of ethical care (Zafarnia et al., 2017). Morally competent nurses can be trusted to deliver quality patient care. They are effective patient advocates and manage ethical issues among patients, significant others, the healthcare team, and other parties. It is important for improving nursing practice as it enables nurses to meet patients’ needs, increasing the public’s satisfaction (Maluwa et al., 2019).
There were reports of perceived negative attitudes and poor performance of nurses in the public, indicating low moral competence levels, thus making them unable to care satisfactorily and defying the nursing code of ethics. The low level of ethical competence among nurses entails the difficulty of handling intricate ethical demands in the delivery of patient care and collaborating with other health workers (Maluwa et al., 2022). There is a gap between the actual nursing care rendered and public expectations, resulting in patient dissatisfaction. Nurses face different moral dilemmas daily and must balance personal morals with nursing responsibilities. Ignoring these problems may lead to burnout, resulting in moral distress, poor professional care, unproductivity, and conflict. Moral distress in clinical settings is associated with low communication, inappropriate decision-making, insufficient staffing, and inadequate provision of care (Berhie, Tezera, & Azagew, 2020). To determine how nurses handle moral dilemmas affecting nursing practice, this study explored the challenges encountered and the strategies employed by nurses when confronted with moral decisions.
METHODOLOGY
This study employed a qualitative research design utilizing in-depth interviews to explore the challenges encountered and the strategies employed by nurses when confronted with moral decisions. The participants consisted of twenty nurse informants recruited through a purposive sampling technique based on these criteria: registered nurse in the Philippines, currently employed as a hospital nurse in Iligan City, Philippines, for at least one year, and willing to participate in the study.
The study was approved by an ethics review committee before starting the work. Permission from the hospital directors was sought, and then the nurses qualifying for the criteria were scheduled for an interview. Informed consent was secured before the one-on-one interview, applying all ethical considerations. A researcher-made interview guide with two open-ended questions was utilized during the unstructured interview sessions, which continued until a new theme emerged. Each interview lasted for 30–60 minutes with an audio recording. The data collection went on for six months, from July to December 2021.
The responses were transcribed verbatim and translated from the vernacular into the English language. Themes were extracted based on thematic analysis by Vaismoradi, Turunen, and Bondas (2013). The truthfulness and accuracy of the data were verified through follow-up interviews with the participants.
Ethical Consideration
The study obtained ethical clearance from the College of Health Sciences Ethics Review Committee of the Mindanao State University-Iligan Institute of Technology, Philippines with code number E-2021-36 on 1st July, 2021.
RESULTS
The Challenges Encountered by Nurses when Confronted with Moral Decisions
Three themes with six sub-themes emerged in the study. The first theme is “predicaments toward patient and family issues”, which includes two sub-themes: patient and family non- conforming decisions and dealing with emotionally burdened family members. The second theme is “recognition of own weaknesses and shortcomings”, which includes four sub-themes: infrequent performance of emotional care, insufficient provision of comfort, interference with patients' privacy, and delays in care due to prioritization. The third theme is “conflict with
superiors”. The participants employed several strategies in addressing the respective moral challenges encountered.
Figure 1: The Emergent Themes and Sub-Themes of the Study
Theme 1 Predicaments toward Patient and Family Issues
The first theme encompasses the moral challenges caused by patient and family circumstances.
Patient/Family Non-Conforming Decisions
This subtheme refers to the inability of the patient or family to abide by the physician’s treatment plan. The participants experienced that the patient or family was not conforming to the medical advice, like refusal to undergo hemodialysis, blood transfusion, resuscitation, and others. Such decisions were mostly due to religious or cultural beliefs and resource constraints.
“One dilemma I encountered was when the patient needed internal jugular catheterization for emergency hemodialysis. The patient and family were undecided because of fear.” – P1
“Several times, I encountered patients refusing blood transfusions due to religious prohibition. It pains me, but I must respect their decision.” – P6
“A challenging situation happened when my patient had cardiopulmonary arrest and the family refused resuscitation because of cultural beliefs.” – P8
“It was heartbreaking when the patient’s family failed to procure medicines or blood components and delayed laboratory tests because of a lack of money.” – P19
Strategies Employed to Address Patient/Family Non-Conforming Decisions
To deal with the patient's or family's non-conforming decisions, the participants explained the treatment thoroughly, respected cultural beliefs, rendered alternative nursing interventions, and referred financial concerns to appropriate agencies.
“For the patient and family to decide on the patient’s treatment, I tried my best to reiterate the doctor’s explanation regarding treatment.” – P1
“Cultural beliefs greatly impact patients’ health perspectives. When they refused treatment, I respected their decision and just rendered alternative nursing interventions.” – P10
“When the patient’s family was unable to procure medicines, blood components, and lab tests, I referred them for financial assistance.” – P8
Dealing with Emotionally Burdened Family Members
This subtheme refers to the inharmonious encounter between the nurse and the patient’s family. Some participants encountered emotionally burdened family members. Dealing with their ungracious behavior aggregates the stress and anxiety already experienced while doing the nursing job.
“Meeting an arrogant patient’s family is inevitable. These rude family members are adding to my stress in caring for various patients.” – P9
“The demanding patients’ families often implied that they could make me lose my job when their requests are not addressed immediately.” – P13
Strategies Employed to Handle the Emotionally Burdened Family Members
The participants dealt with emotionally burdened family members by explaining hospital policies and elevating unresolved issues to higher authority in the hospital.
“To deal with arrogance, I just explained that we prioritize urgent cases and will attend to them shortly. Situations beyond control were elevated to a higher authority.” – P9
Theme 2: Recognition of Weaknesses and Shortcomings
The second theme pertains to the moral challenges caused by nursing circumstances. This involves the dilemmas of nurses in recognizing and dealing with their weaknesses and shortcomings in performing nursing responsibilities.
Infrequent Performance of Emotional Care
The participants claimed that the patient’s emotional well-being sometimes lapsed because they prioritized physical care. This resulted from insufficient time to perform emotional care from understaffing.
“I couldn’t give quality time to patients because of understaffing problems. I sometimes left out rendering emotional care.” – P12
“During rounds, I sometimes missed letting the patients express their feelings and concerns because I hurried to perform plenty of nursing interventions.” – P14
The Strategy Employed to Address the Infrequent Performance of Emotional Care
A participant remarked that she addressed her deficiency in performing emotional care for patients by encouraging the expression of feelings when time allowed.
“To compensate for my shortcomings in emotional care, I tried finding time to ask patients the most important thing they wanted for the day, letting them verbalize their feelings.” – P12
Insufficient Provision of Comfort
When the patient is in pain, the nurse is inclined to render pain relief immediately. When pain medication is unavailable, the nurse renders non-pharmacologic management. However, some conditions necessitate pain medication. A participant shared that she felt inadequate in alleviating the patient’s pain when the family was financially constrained to buy medicine.
“I had difficulty alleviating the patient's pain when the family had no money to buy medicine. I felt my non-pharmacologic management was inadequate, and it was distressing.” – P3
Strategies Employed to Address the Insufficient Provision of Comfort
Pain management must be rendered immediately to prevent untoward physical and psychological outcomes. When the family was unable to procure pain medication, the nurses helped by securing extra medicines for the patient and referring the need to appropriate agencies.
“If the patient has no money to buy a pain reliever, I tried to look for extra medicines that I could use and exerted effort in referring the concern to charitable agencies.” – P3
Interference with Patient’s Privacy
A participant stressed that she couldn’t avoid discussing the patients’ information with other nurses. The nurse cannot avoid sharing the patients’ concerns with colleagues to solicit ideas on how she can assist with the patients' problems.
“I and my colleagues cannot keep away from talking about patients' information at the nurse’s station.” – P4
The Strategy Employed to address Interference with Patients' Privacy
A participant recognized that sharing a patient’s confidential information violates a patient’s rights. Thus, she tried to avoid discussing and sharing private data with those uninvolved in the care.
“I tried to observe confidentiality by only sharing patients' confidential information with those involved in patient care.” – P4
Delays in Care Due to Prioritization
A participant stated that sometimes some nursing interventions were rendered late because of the numerous nursing interventions to be done for many patients.
“Sometimes I was delayed in administering medications or blood components because I was busy attending to other patients. I rendered my care according to the urgency of my needs.” – P16
The Strategy Employed to Address Delays in Care Due to Prioritization
Sometimes, it is imminent that specific patient care can be delayed. A participant claimed that it resulted from patient overload, especially in government hospitals. Thus, the nurse in charge cannot avoid endorsing some procedures from the incoming nurse.
“In times that I failed to perform all nursing interventions due during my shift, I just politely endorsed them to the incoming nurse.” – P16
Theme 3: Conflict with Superiors
The third theme refers to the moral challenge caused by pressure from higher authorities in the hospital. A participant disclosed that she was requested to go on duty by her supervisors despite her exposure to a COVID-19-positive colleague, despite not being tested and quarantined.
“I was in close contact with a COVID-19-positive colleague. I was not tested or quarantined. Since I didn’t manifest symptoms, my supervisors asked me to go on duty.” – P20
The Strategy Employed to Address Conflict with Superiors
Having a conflicting decision with higher authority gives the nurse a moral dilemma. The nurse dealt with the situation by tactfully communicating with the supervisors about her decision to abstain from duty.
“I politely informed my superiors that I preferred not to go on duty to ensure I would not endanger my patients and colleagues in case I contracted the COVID-19 infection.” – P20
DISCUSSION
Nurses in different environments may face similar challenges when making moral decisions during their practice, reflecting common difficulties experienced by participants in such situations. These difficulties could give nurses a hard time performing nursing interventions and may result in emotional distress and burnout.
It is morally distressing for the nurse when the patient's or family's decision opposes medical advice. When the patient doesn’t comply with the treatment plan, worsening conditions and complications usually occur. The patient’s non-conformance to treatment is mainly due to denial of the problem, treatment cost, regimen difficulty, side effects, lack of trust, apathy, and previous experience (Torrey, 2022). Cultural beliefs influence patients to resist medical and nursing management, which dismays nurses. As the patient or family gets offended when the nurse doesn’t recognize their cultural practice, the nurse is also troubled by witnessing things against her personal beliefs. According to Markey (2021), cultural competence among healthcare professionals is developing; however, insensitivity and deficiencies in care for culturally diverse patients prevail. Exploring cultural competence development through a moral perspective can empower nurses and cultivate commitment and courage to render quality care meeting patients' culturally diverse needs. Another reason for defying medical advice was a lack of medications and supplies due to financial constraints. This sad reality gives the nurse some frustration and guilt because the patient receives delayed treatment due to deficient resources. Another study demonstrates that nurse managers, in particular, play a significant role in managing their subordinates' frustrations, which, in turn, has a direct impact on their work performance and the quality of patient care (Garces-Cabanas, & Dano, 2022).
Explaining the treatment thoroughly or reinforcing the doctor’s explanation allowed an opportunity for queries from the patient or family, resulting in favorable decisions. Several methods also improved patient compliance, such as providing clear and concise instructions, adjusting regimens to everyday routines, inducing patient participation in treatment through self-monitoring, and furnishing educational materials. In whatever strategy, it is important to identify the patient’s weaknesses in enduring treatment and give the necessary education and support to comply with therapy (Wolters Kluwer, 2017). The educational guidelines had a beneficial impact on the knowledge and skills of intern nurses when it came to the decision- making process (Ahmed, Zaghlol, & Tawfik, 2018).
Caring for culturally diverse families is satisfying yet demanding and challenging because of communication barriers, cultural expression, and the ethical responsibility of care (Murcia & Lopez, 2016). Cultural respect enables nurses to serve diverse patients by respecting their health beliefs and practices and responding to their cultural and linguistic needs, thus positively impacting patient care delivery (National Institutes of Health, n.d.). When the nurse respects the patient's or family's decision to oppose medical advice, he or she feels tormented. The participants compensated by rendering safe alternative interventions acceptable to the patients’ cultures. Good clinical communication, which is respectful, clear, direct, and explicit, is crucial. On the other hand, poor communication can cause stress, frustration, and mistrust, leading to lower-quality care and a higher risk of medical errors. Nurses and doctors play a vital role in building good relationships to ensure high-quality patient care. Another study found that communication skills are influenced by nursing training, nurses' personal qualities, and their work environment (Kunjukunju, & Ahmad, 2019).
Financial constraints tremendously affect the patient’s adherence to treatment. Financial toxicity creates distress, anxiety, and depression, threatening the patient’s optimum health (Ramsey et al., 2016). Nurses may not lift all barriers to patient treatment; however, they can provide support through referrals. Being a patient advocate greatly impacts improving patient outcomes (Wiley, 2016). The participants exercised a patient advocate role by referring patients to agencies granting medical financial assistance. The gesture benefits the patients and simultaneously boosts the nurses’ morale.
The patient or family may appear rude due to fear, frustration, pain, or some complex social, physical, or mental matter (Godfrey, 2016). The nurse must discern why the patient’s family displays a displeasing attitude. They may be stressed about the patient’s condition and worried about finances, resulting in embarrassing statements or aggressive behavior. Stress due to fear and anxiety induces the patient’s family to exhibit undesirable behavior toward hospital staff. Unruly behavior is common among family members who were the patient’s caregivers at home, wanting optimal care for the patient. Explaining the hospital's policies helps the patient’s family understand why they must wait to be attended to. The nurse must be honest, set realistic expectations, spend more time communicating, and involve the family in patient care (McCutcheon, 2022). These acquaint the family with the patient’s condition and treatment, decreasing anxiety and stress. The nurse should establish rapport and let the family express their worries and concerns. For issues beyond control, reporting to superiors will offer a better solution to the problem.
Emotional support is essential in preventing a patient’s emotional distress, which delays recovery and contributes to pain and other physical symptoms. Meeting the patient’s emotional needs reduces stress and suffering and provides comfort (Molazem & Ghadakpour, 2013). Stable emotional and mental status results in better patient outcomes, and nurses are the right people to assist patients in facing challenges (Lamar University, 2020). Emotional support is demonstrated through warmth and kindness, deep listening, and social connection in the treatment process (Bradshaw et al., 2022). The nurse’s compassionate behavior has a high emotional effect on patients, making them feel considered and cared for. However, emotional care is often neglected because healthcare delivery systems are more focused on physical care. This study shows that nurses have an inadequate relationship with some patients due to time constraints related to workload. It is morally challenging for a nurse whenever he or she misses providing emotional care. Thus, the participants need to give more time and effort to emotional care.
The insufficient provision of patient comfort, especially during pain, was one moral challenge encountered by nurses. If pain is not properly managed, patients may experience distressing symptoms like anxiety, sadness, weariness, a desire to end their lives, worsening of the condition, limitations on activities of daily living, poor treatment compliance, and extended hospital stays (Germossa, Helleso, & Sjetne, 2019). Therefore, nurses must prioritize pain relief so patients will feel comfortable and satisfied. The nurses are compelled to be resourceful to help the patient relieve pain. The nurse’s primary role is to provide comfort while noting if the pain signals an underlying disease (Aller, 2019). This study shows that nurses tried their best to address problems interfering with patients’ comfort. They exerted effort in acquiring patients’ pain medications and referred them to agencies granting medical financial assistance. This agrees with Becker, Wright, and Schmit (2017) that nurses meet patients' demands for optimal physical care, including pain management, and foster a calm environment.
Observing confidentiality means showing respect and motivating the patient to supply personal information necessary for diagnosing and treating disease. Patients not only experience discomfort in settings that lack privacy but also seek assurance that health workers will safeguard disclosed information (Demirsoy & Kirimlioglu, 2016). However, the nurse can sometimes divulge critical information to other nurses due to concerns that challenge confidentiality. Nurses’ knowledge about the importance of protecting patients’ privacy is higher compared to their actual performance (Kim, Han, & Kim, 2017). The participants are still striving to overcome the challenge of maintaining patients’ privacy and confidentiality. To improve the nurses’ knowledge and attitudes toward patient confidentiality, medical ethics should be focused on during the orientation of new nurses and in-service training (Tegegne et al., 2022).
The nurses are confronted with various challenges in promptly meeting the patient’s healthcare needs. These include the irregularity of the quantity and quality of staffing, nurse-patient ratios, number of duty hours, deficient equipment and supplies, and the intensity of nursing care required by patients. The nurses must decide what actions to prioritize; however, they may experience moral distress as they feel guilty and frustrated about the delayed or missed care (Winters & Neville, 2012). The participant prioritized the delivery of care according to urgency. Though the nurse wants to finish all due procedures, it is unavoidable that some cannot be done. Thus, endorsing the missed procedures for the next shift is paramount. The constant endorsement of unfinished nursing interventions may cause emotional and physical burdens for the receiving nurse, resulting in conflict. Healthcare organizations can create a workplace that enhances the well-being and resilience of their nurses by acknowledging the specific difficulties nurses encounter and offering tailored assistance (Sillero Sillero et al., 2023).
It is morally acceptable that healthcare workers abstain from duty when performing patient care because the risks and burdens of doing so outweigh the benefits (McConnell, 2020). The participant decided to refuse their superiors’ order to protect her colleagues and patients from a possible COVID-19 infection. The nurse was constructive during the conflict situation, ensuring the superiors understood her decision. Aggressive behavior must be avoided; instead, supportive behavior must be demonstrated to attain respect from both parties (Labrague, Al Hamdan, & McEnroe-Petite, 2018). Being a nurse involves a lot of communicating with others in challenging situations that can sometimes cause tension. Thus, strong conflict resolution skills are necessary to solve issues not just with patients but with colleagues and superiors alike. Conflict resolution in nursing is important as it reduces stress and promotes good work relationships.
CONCLUSION
Moral competence is inherent in nurses, as they exhibit moral judgment and skills in overcoming the moral challenges encountered. However, there are moral issues beyond control in patient care. Therefore, hospital administrators may conduct a program to enhance the nurses’ competence to handle moral challenges and prevent moral distress, which will eventually improve nursing practice. This study can also be the basis for developing a moral competence self-assessment tool to empower hospital nurses to examine their morals and change for better nursing care.
Conflict of Interest
The author has no conflict of interest to declare.
ACKNOWLEDGMENT
The author is thankful to the institutional authority for completion of the work.
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