Nurses' tension-based ethical decision making in rural acute care settings

Abstract

Background Nurses in acute care are frequently involved in ethical decision making and experience a higher prevalence of ethical conflicts and dilemmas. Nurses in underresourced rural acute care settings also are likely to face unique ethical challenges. However, rarely have the particular contexts of these experiences in rural acute care settings been researched. A culture of silence and fear in small towns has made exploring these issues difficult. Objectives To explore registered nurses’ experiences of ethical issues and ethical decision making in rural acute care hospitals in northern Ontario, Canada. Research design Guided by an interpretive descriptive approach, data were collected by two nurse researchers using in-depth, individual, and semistructured telephone interviews. Data were managed with NVivo v.11 and analyzed using inductive, comparative, thematic analyses. Participants and research context The participants were eight registered nurses working in two acute care hospitals in northern Ontario. Ethical considerations Ethical protocols were followed in accordance with ethics approval from the researchers’ university and the hospitals. Findings Results identified four themes that culminated in the development of a quadruple helix ethical decision-making framework of power, trust, care, and fear. Discussion and conclusion The participants described complex ethical conflicts and dilemmas in acute care settings that were influenced by the context of working and living in small rural communities in northern Ontario. Nurses described navigating ethics in practice using a tension-based approach to ethical decision making, needing to carry these issues silently and often having no resolution to ethical challenges. These findings have important implications for nursing education, research, and practice. Nurses need safe spaces, formal ethics support, and improved access to resources. Additional ethics education and training specific to the unique contexts of rural settings are needed.

Into the Grey Zone: Retired Nurses’ Reflections on Ethics in Canadian Nursing Practice

“…Situations that require moral courage have been categorized in the literature to include seven key aspects: colleagues, managers, physicians, nurses themselves, patients, patients' relatives, and organizations (40). These groupings also have been identified by nurses as factors that create ethical challenges and require tension-based ethical decisions (41,42). Moral courage helps nurses respond to ethical issues and to act to do the right thing when that choice is not easy and is probably risky (41).…”

“…Next steps for research may include a concept analysis of the three themes (i.e., fellowship, ingenuity, and gumption) in followup studies to more clearly define these concepts and perhaps develop a framework or model to guide nursing ethics education and/or ethics in nursing practice. Further, this study contributes to a small body of academic literature on ethical issues and ethical decision-making among nurses working in acute care locations in northern Ontario, Canada (42). More studies that address ethical issues in various health care sectors in small communities, and rural or remote locations are needed, particularly to continue to explore the unique relational and multi-layered aspects of health care in these settings (16).…”

Conscientious objection to medical assistance in dying in rural/remote nursing

“… 17 Grappling with ethical issues and experiencing compassion-fatigue are common themes to nurses working in rural and remote areas in countries with widely dispersed populations such as Australia, Canada, and the United States. 18 – 20…”

Operational framework for rural hospitals during a pandemic

“…Thus, metrocentric frameworks such as these may not be very helpful in rural settings that are resource poor [8] or resource constrained [6]. Further, the hallmark of a rural community is that everyone seems to know everyone [9]. Therefore, ethical decisions in rural health care are rarely abstract; they are concrete decisions that often affect friends, neighbours, and colleagues [9].…”

“…Further, the hallmark of a rural community is that everyone seems to know everyone [9]. Therefore, ethical decisions in rural health care are rarely abstract; they are concrete decisions that often affect friends, neighbours, and colleagues [9]. Thus we propose a decision making framework and team approach to maximize the potential to maintain provider-patient relationships during care in austere and unprecedented times [10].…”