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The Nature of Ethical Conflicts and the Meaning of Moral Community in Oncology Practice

Carol Pavlish
Katherine Brown-Saltzman
Patricia Jakel
Alyssa Fine
ONF 2014, 41(2), 130-140 DOI: 10.1188/14.ONF.130-140

Purpose/Objectives: To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated.

Research Approach: Ethnography.

Setting: Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota.

Participants: 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists.

Methodologic Approach: 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes.

Findings: Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources.

Conclusions: Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter.

Interpretation: Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.

References 

Agich, G.J. (2011). Defense mechanisms in ethics consultation. <i>HEC Forum, 23</i>, 269-279. doi:10.1007/s10730-011-9165-6

Aiken, L.H., Clarke, S.P., Sloane, D.M., Lake, E.T., & Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. <i>Journal of Nursing Administration, 38</i>, 223-229. doi:10.1097/01.NNA.0000312773.42352.d7

Austin, W. (2007). The ethics of everyday practice: Healthcare environments as moral communities. <i>Advances in Nursing Science, 30</i>, 81-88. doi:10.1097/00012272-200701000-00009

Austin, W. (2012). Moral distress and the contemporary plight of health professionals. <i>HEC Forum, 24</i>, 27-38. doi:10.1007/s10730-012-9179-8

Azoulay, E., Timsit, J.F., Sprung, C.L., Soares, M., Rusinóva, K., Lafabrie, A., … Schlemmer, B. (2009). Prevalence and factors of intensive care conflicts: The conflicus study. <i>American Journal of Respiratory and Critical Care Medicine, 180</i>, 853-860. doi:10.1164/rccm.200810-1614OC

Baer, L., & Weinstein, E. (2013). Improving oncology nurses' communication skills for difficult conversations [Online exclusive]. <i>Clinical Journal of Oncology Nursing, 17</i>, E45-E51. doi:10.1188/13.CJON.E45-E51

Balevre, P.S., Cassells, J., & Buzaianu, E. (2012). Professional nursing burnout and irrational thinking: A replication study. <i>Journal for Nurses in Staff Development, 28</i>, 2-8. doi:10.1097/NND.0b013e318240a65a

Barsky, A. (2008). A conflict resolution approach to teaching ethical decision making: Bridging conflicting values. <i>Journal of Jewish Communal Service, 83</i>, 164-169.

Boyle, D.K., Miller, P.A., & Forbes-Thompson, S.A. (2005). Communication and end-of-life care in the intensive care unit: Patient, family, and clinician outcomes. <i>Critical Care Nursing Quarterly, 28</i>, 302-316. doi:10.1097/00002727-200510000-00002

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

Chen, A.B., Cronin, A., Weeks, J.C., Chrischilles, E.A., Malin, J., Hayman, J.A., & Schrag, D. (2013). Expectations about the effectiveness of radiation therapy among patients with incurable lung cancer. <i>Journal of Clinical Oncology, 31</i>, 2730-2735. doi:10.1200/JCO.2012.48.5748

Cimiotti, J.P., Aiken, L.H., Sloane, D.M., & Wu, E.S. (2012). Nurse staffing, burnout, and health care-associated infections. <i>American Journal of Infection Control, 40</i>, 486-490. doi: 10.1016/j.ajic.2012.02.029

Coomber, B., & Barriball, K.L. (2007). Impact of job satisfaction components on intent to leave and turnover in hospital-based nurses: A review of the research literature. <i>International Journal of Nursing Studies, 44</i>, 297-314. doi: 10.1016/j.ijnurstu.2006.02.004

Danjoux Meth, N., Lawless, B., & Hawryluck, L. (2009). Conflicts in the ICU: Perspectives of administrators and clinicians. <i>Intensive Care Medicine, 35</i>, 2068-2077. doi:10.1007/s00134-009-1639-5

Edelstein, L.M., DeRenzo, E.G., Waetzig, E., Zelizer, C., & Mokwunye, N.O. (2009). Communication and conflict management training for clinical bioethics committees. <i>HEC Forum, 21</i>, 341-349. doi:10.1007/s10730-009-9116-7

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

Estabrooks, C.A., Midodzi, W.K., Cummings, G.G., Ricker, K.L., & Giovannetti, P. (2005). The impact of hospital nursing characteristics on 30-day mortality. <i>Nursing Research, 54</i>, 74-84. doi:10.1097/00006199-200503000-00002

Fairchild, R.M. (2010). Practical ethical theory for nurses responding to complexity in care. <i>Nursing Ethics, 17</i>, 353-362. doi:10.1171/0969733010361442

Fassier, T., & Azoulay, E. (2010). Conflicts and communication gaps in the intensive care unit. <i>Current Opinion in Critical Care, 16</i>, 654-665. doi:10.1097/MCC.0b013e32834044f0

Ferrell, B.R. (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

Friese, C.R. (2005). Nurse practice environments and outcomes: Implications for oncology nursing. <i>Oncology Nursing Forum, 32</i>, 765-772. doi:10.1188/05.ONF.765-772

Gaudine, A., LeFort, S.M., Lamb, M., & Thorne, L. (2011). Ethical conflicts with hospitals: The perspective of nurses and physicians. <i>Nursing Ethics, 18</i>, 756-766. doi:10.1177/0969733011401121

Gutierrez, K.M. (2005). Critical care nurses' perceptions of and responses to moral distress. <i>Dimensions of Critical Care Nursing, 24</i>, 229-241. doi:10.1097/00003465-200509000-00011

Hamric, A.B. (2012). Empirical research on moral distress: Issues, challenges, and opportunities. <i>HEC Forum, 24</i>, 39-49. doi:10.1007/s10730-012-9177-x

Hamric, A.B., & Blackhall, L.J. (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. doi:10.1111/j.1466-769X.2004.00160.x

Ho, A. (2009). "They just don't get it!" When family disagrees with expert opinion. <i>Journal of Medical Ethics, 35</i>, 497-501. doi:10.1138/jme.2008.028555

Institute of Medicine. (2010). <i>The future of nursing: Leading change, advancing health: Report recommendations.</i> Retrieved from <a target="_blank" href='http://bit.ly/1aMfX33'>http://bit.ly/1aMfX33</a>

MacQueen, K.M., McLellan-Lemal, E., Bartholow, K., & Milstein, B. (2008). Team-based codebook development: Structure, process, and agreement. In G. Guest & K. MacQueen (Eds.), <i>Handbook for team-based qualitative research</i> (pp. 119-135). Lanham, MD: AltaMira.

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

Manojlovich, M. (2005). Linking the practice environment to nurses' job satisfaction through nurse-physician communication. <i>Journal of Nursing Scholarship, 37</i>, 367-373. doi:10.1111/j.1547-5069.2005.00063.x

McAndrew, N.S., Leske, J.S., & Garcia, A. (2011). Influence of moral distress on the professional practice environment during prognostic conflict in critical care. <i>Journal of Trauma Nursing, 18</i>, 221-230. doi:10.1097/JTN.0b013e31823a4a12

McClendon, H., & Buckner, E.B. (2007). Distressing situations in the intensive care unit: A descriptive study of nurses' responses. <i>Dimensions of Critical Care Nursing, 26</i>, 199-206. doi:10.1097/01.DCC.0000286824.11861.74

McCullough, L.B. (2012). An ethical framework for the responsible leadership of accountable care organizations. <i>American Journal of Medical Quality, 27</i>, 189-194. doi:10.1177/1062860611421226

Medland, J., Howard-Ruben, J., & Whitaker, E. (2004). Fostering psychosocial wellness in oncology nurses: Addressing burnout and social support in the workplace. <i>Oncology Nursing Forum, 31</i>, 47-54. doi:10.1188/04.ONF.47-54

Molewijk, B., Kleinlugtenbelt, D., Pugh, S.M., & Widdershoven, G. (2011). Emotions and clinical ethics support: A moral inquiry into emotions in moral case deliberation. <i>HEC Forum, 23</i>, 257-268. doi:10.1007/s10730-011-9162-9

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

Nelson, W.A., Weeks, W.B., & Campfield, J.M. (2008). The organizational costs of ethical conflicts. <i>Journal of Healthcare Management, 53</i>, 41-52.

Page, A. (Ed.). (2004). <i>Keeping patients safe: Transforming the work environment for nurses and patient safety.</i> Washington, DC: National Academies Press.

Pavlish, C., Brown-Saltzman, K., Hersh, M., Shirk, M., & Nudelman, O. (2011). Early indicators and risk factors for ethical issues in clinical practice. <i>Journal of Nursing Scholarship, 43</i>, 13-21. doi:10.1111/j.1547-5069.2010.01380.x

Pavlish, C., Brown-Saltzman, K., Jakel, P., & Rounkle, A.M. (2012). Nurses' responses to ethical challenges in oncology: An ethnographic study. <i>Clinical Journal of Oncology Nursing, 16</i>, 592-600. doi:10.1188/12.CJON.592-600

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

Peter, E., Lunardi, V.L., & Macfarlane, A. (2004). Nursing resistance as ethical action: Literature review. <i>Journal of Advanced Nursing, 46</i>, 403-416. doi:10.1111/j.1365-2648.2004.03008.x

Reilly, P. (2010). Mindfulness, emotions, and mental models: Theory that leads to more effective dispute resolution. <i>Nevada Law Journal, 10</i>(2), 433-460.

Rice, E.M., Rady, M.Y., Hamrick, A., Verheijde, J.L., & Pendergast, D.K. (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

Richard, L., Gauvin, L., & Raine, K. (2011). Ecological models revisited: Their uses and evolution in health promotion over two decades. <i>Annual Review of Public Health, 32</i>, 307-326.

Rosenstein, A.H., & O'Daniel, M. (2005). Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. <i>American Journal of Nursing, 105</i>, 54-64. doi:10.1097/00000446-200501000-00025

Russell, A.C. (2012). Moral distress in neuroscience nursing: An evolutionary concept analysis. <i>Journal of Neuroscience Nursing, 44</i>, 15-24. doi:10.1097/JNN.0b013e31823ae4cb

Schlairet, M.C. (2009). Bioethics mediation: The role and importance of nursing advocacy. <i>Nursing Outlook, 57</i>, 185-193. doi:10.1016/j.outlook.2008.10.006

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

Storch, J.L., & Kenny, N. (2007). Shared moral work of nurses and physicians. <i>Nursing Ethics, 14</i>, 478-491. doi:10.1177/0969733007077882

Streubert, H.J. (2011). Ethnography as method. In H.J. Streubert & D.R. Carpenter (Eds.), <i>Qualitative research in nursing: Advancing the humanistic imperative.</i> (5th ed., pp. 167-196). Philadelphia, PA: Lippincott Williams and Wilkins.

Swetz, K.M., Crowley, M.E., Hook, C., & Mueller, P.S. (2007). Report of 255 clinical ethics consultations and review of the literature. <i>Mayo Clinic Proceedings, 82</i>, 686-691.

Van Soeren, M., & Miles, A. (2003). The role of teams in resolving moral distress in intensive care unit decision-making. <i>Critical Care, 7</i>, 217-218. doi:10.1186/cc2168

Varcoe, C., Pauly, B., Storch, J., Newton, L., & Makaroff, K. (2012). Nurses' perceptions of and responses to morally distressing situations. <i>Nursing Ethics, 19</i>, 488-500. doi:10.1177/0969733011436025

Wang, T. (2013). A piece of my soul. <i>Intensive Care Medicine, 39</i>, 1137-1138. doi:10.1007/s00134-013-2883-2

Webster, G.C., & Baylis, F.E. (2000). <i>Moral residue.</i> In S.B. Rubin & L. Zoloth (Eds.), <i>Margin of error: The ethics of mistakes in the practice of medicine</i> (pp. 217-230). Hagerstown, MD: University Publishing Group.

Weeks, J.C., Catalano, P.J., Cronin, A., Finkelman, M.D., Mack, J.W., Keating, N.L., & Schrag, D. (2012). Patients' expectations about effects of chemotherapy for advanced cancer. <i>New England Journal of Medicine, 367</i>, 1616-1625. doi:10.1056/NEJMoa1204410

Wiegand, D.L., & Funk, M. (2012). Consequences of clinical situations that cause critical care nurses to experience moral distress. <i>Nursing Ethics, 19</i>, 479-487. doi:10.1177.0969733011429342

Winland-Brown, J.E., Chiarenza, D., & Dobrin, A. (2010). <i>Nurse-physician perspectives on moral distress support the need to create a caring ethical environment.</i> Retrieved from <a target="_blank" href='http://forumonpublicpolicy.com/spring2010.vol2010/spring2010archive/winl...

Wlodarczyk, D., & Lazarewicz, M. (2011). Frequency and burden with ethical conflicts and burnout in nurses. <i>Nursing Ethics, 18</i>, 847-861. doi:10.1177/0969733011408053