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Nurses' Responses to Ethical Challenges in Oncology Practice: An Ethnographic Study

Carol Pavlish
Katherine Brown-Saltzman
Patricia Jakel
Ann-Marie Rounkle
CJON 2012, 16(6), 592-600 DOI: 10.1188/12.CJON.592-600

Oncology nurses encounter increasingly complex ethical challenges in clinical practice. This ethnographic study explored 30 oncology nurses' descriptions of ethical situations and 12 key informants' perspectives on factors that influence the development of ethically difficult situations. Nurses described the goals of preventing patient suffering and injury, being honest with patients, and contributing meaningfully to patient improvement and stated goals. Nurses experienced six primary challenges in meeting their goals: being the eyes and arms of patient suffering, experiencing the precariousness of competing obligations, navigating the intricacies of hope and honesty, managing the urgency caused by waiting, straining to find time, and weighing risks of speaking up in hierarchal structures. Nurse actions included addressing concerns, creating other avenues, murmuring to one another, staying silent, and looking away. Several factors influenced nurses' responses to ethical challenges. Results imply a contextual model of moral action that reveals a need for altering practice environments in addition to improving nurses' ethics skills. Nurses are very aware of their moral responsibilities in ethically difficult situations and need work environments conducive to interprofessional collaboration and open dialogue.


American Nurses Association. (2001). <i>Code of ethics for nurses with interpretive statements.</i> Washington, DC: Author.

American Nurses Association. (2010). <i>Registered nurses' roles and responsibilities in providing expert care and counseling at the end of life</i> [Position statement]. Retrieved from <a target="_blank" href='http://www.nursingworld.org/MainMenuCategories/EthicsStandards/Ethics-Po...

Attree, M. (2007). Factors influencing nurses' decisions to raise concerns about care quality. <i>Journal of Nursing Management, 15</i>, 392-402.

Bowles, C., & Candela, L. (2005). First job experiences of recent RN graduates: Improving the work environment. <i>Journal of Nursing Administration, 35</i>, 130-137.

Campbell, D. A., Jr., & Cornett, P. L. (2002). How stress and burnout produce medical mistakes. In M. Rosenthal & K. Sutcliffe (Eds.), <i>Medical error: What do we know? What do we do?</i> (pp. 37-57). San Francisco, CA: Jossey-Bass.

Chambliss, D. (1996). <i>Beyond caring: Hospitals, nurses, and the social organization of ethics.</i> Chicago, IL: University of Chicago.

Chen, P. (2007). <i>Final exam: A surgeon's reflections on mortality.</i> New York, NY: Alfred A. Knopf.

Cohen, J. S., & Erickson, J. (2006). Ethical dilemmas and moral distress in oncology nursing practice. <i>Clinical Journal of Oncology Nursing, 10</i>, 775-780. doi:10.1188/06.CJON.775-780

Corley, M., Minick, P., Elswick, R., & Jacobs, M. (2005). Nurse moral distress and ethical work environment. <i>Nursing Ethics, 12</i>, 381-390. doi:10.1191/0969733005ne809oa

Elpern, E., Covert, B., & Kleinpell, R. (2005). Moral distress of staff nurses in a medical intensive care unit. <i>American Journal of Critical Care, 14</i>, 523-530.

Epstein, E., & Hamric, A. (2009). Moral distress, moral residue, and the crescendo effect. <i>Journal of Clinical Ethics, 20</i>, 330-342.

Ferrell, B. (2006). Understanding the moral distress of nurses witnessing medically futile care. <i>Oncology Nursing Forum, 33</i>, 922-930. doi:10.1188/06.onf.922-930

Goethals, S., Gastmans, C., & Dierckx de Casterlé, B. (2010). Nurses' ethical reasoning and behaviour: A literature review. <i>International Journal of Nursing Studies, 47</i>, 635-650. doi:10.1016/j.ijnurstu.2009.12.010

Gutierrez, K. (2005). Critical care nurses' perceptions of and responses to moral distress. <i>Dimensions of Critical Care Nursing, 24</i>, 229-241.

Hamric, A. (2001). Reflections on being in the middle. <i>Nursing Outlook, 49</i>, 254-257. doi:10.1067/mno.2001.120247

Hamric, A., & Blackhall, L. (2007). Nurse-physician perspectives on the care of dying patients in intensive care units: Collaboration, moral distress, and ethical climate. <i>Critical Care Medicine, 35</i>, 422-429. doi:10.1097/01.ccm.0000254722.50608.2D

Hardingham, L. B. (2004). Integrity and moral residue: Nurses as participants in a moral community. <i>Nursing Philosophy, 5</i>, 127-134.

Hart, S. (2005). Hospital ethical climates and registered nurses' turnover intentions. <i>Journal of Nursing Scholarship, 37</i>, 173-177.

Jameton, A. (1984). <i>Nursing practice: The ethical issues.</i> Englewood Cliffs, NJ: Prentice-Hall.

Jameton, A. (1993). Dilemmas of moral distress: Moral responsibility and nursing practice. <i>AWHONN'S Clinical Issues in Perinatal and Women's Health Nursing, 4</i>, 542-551.

Kubsch, S. M., Sternard, M. J., Hovarter, R., & Matzke, V. (2004). A holistic model of advocacy: Factors that influence its use. <i>Complementary Therapies in Nursing and Midwifery, 10</i>, 37-45.

Langeland, K., & Sørlie, V. (2011). Ethical challenges in nursing emergency practice. <i>Journal of Clinical Nursing, 20</i>, 2064-2070.

Maiden, J., Georges, J. M., & Connelly, C. D. (2011). Moral distress, compassion fatigue, and perceptions about medication errors in certified critical care nurses. <i>Dimensions of Critical Care Nursing, 30</i>, 339-345. doi:10.1097/DCC.0b013e31822fab2a

McClendon, H., & Buckner, E. (2007). Distressing situations in the intensive care unit: A descriptive study of nurses' responses. <i>Dimensions of Critical Care Nursing, 26</i>, 199-206.

Meltzer, L., & Huckabay, L. (2004). Critical care nurses' perceptions of futile care and its effect on burnout. <i>American Journal of Critical Care, 13</i>, 202-208.

Morris, P., & Dracup, K. (2008). Time for a tool to measure moral distress? <i>American Journal of Critical Care, 17</i>, 398-401.

Oncology Nursing Society. (2010a). <i>Oncology Nursing Society and Association of Oncology Social Work joint position statement on palliative and end-of-life care</i>. Retrieved from <a target="_blank" href='http://www.ons.org/publications/media/ons/docs/positions/summary-end-of-...

Oncology Nursing Society. (2010b). <i>Oncology Nursing Society position statement on the nurse's responsibility to patients requesting assistance in hastening death.</i> Retrieved from <a target="_blank" href='http://www.ons.org/Publications/Positions/AssistedSuicide/media/ons/docs...

Pavlish, C., Brown-Saltzman, K., Hersh, M., Shirk, M., & Rounkle, A. (2011). Nursing priorities, actions, and regrets for ethical issues in clinical practice. <i>Journal of Nursing Scholarship, 43</i>, 385-395.

Pendry, P. (2007). Moral distress: Recognizing it to retain nurses. <i>Nursing Economic, 25</i>, 217-221.

Penticuff, J., & Walden, M. (2000). Influence of practice environment and nurse characteristics on perinatal nurses' responses to ethical dilemmas. <i>Nursing Research, 49</i>, 64-72.

Pergert, P., & Lützén, K. (2012). Balancing truth-telling in the preservation of hope: A relational ethics approach. <i>Nursing Ethics, 19</i>, 21-29. doi:10.1177/0969733011418551

Peter, E., & Liaschenko, J. (2004). Perils of proximity: A spatiotemporal analysis of moral distress and moral ambiguity. <i>Nursing Inquiry, 11</i>, 218-225.

Raines, M. (2000). Ethical decision making in nurses: Relationships among moral reasoning, coping style, and ethics stress. <i>JONA's Healthcare Law, Ethics and Regulation, 2</i>, 29-41.

Rice, E., Rady, M., Hamrick, A., Verheijde, J., & Pendergast, D. (2008). Determinants of moral distress in medical and surgical nurses at an adult acute tertiary care hospital. <i>Journal of Nursing Management, 16</i>, 360-373. doi:10.1111/j.1365-2384.2007.00796.x

Saldaña, J. (2009). <i>The coding manual for qualitative researchers.</i> Los Angeles, CA: Sage.

Schluter, J., Winch, S., Holzhauser, K., & Henderson, A. (2008). Nurses' moral sensitivity and hospital ethical climate: A literature review. <i>Nursing Ethics, 15</i>, 304-321. doi:10.1177/0969733007088357

Shepard, A. (2010). Moral distress: A consequence of caring. <i>Clinical Journal of Oncology Nursing, 14</i>, 25-27. doi:10.1188/10.CJON.25-27

Sørlie, V., Kihlgren, A., & Kihlgren, M. (2005). Meeting ethical challenges in acute care nursing care as narrated by registered nurses. <i>Nursing Ethics, 12</i>, 133-142. doi:10.1191/0969733005ne770oa

Speziale, H. (2007). Ethnography as method. In H. Speziale & D. Carpenter (Eds.), <i>Qualitative research in nursing: Advancing the humanistic imperative</i> (pp. 195-226). Philadelphia, PA: Lippincott Williams and Wilkins.

Ulrich, C., Hamric, A., & Grady, C. (2010). Moral distress: A growing problem in health professions? <i>Hastings Center Report, 40</i>, 20-22.