MEETING ETHICAL CHALLENGES IN ACUTE CARE WORK AS NARRATED BY ENROLLED NURSES

Venke Srlie, Annica Larsson Kihlgren and Mona Kihlgren

Key words : acute care; confirmation; conscience; enrolled nurses; ethics; narrative; responsibility; work environment Five enrolled nurses (ENs) were interviewed as part of a comprehensive investigation into the narratives of registered nurses, ENs and patients about their experiences in an acute care ward. The ward opened in 1997 and provides patient care for a period of up to three days, during which time a decision has to be made regarding further care elsewhere or a return home. The ENs were interviewed concerning their experience of being in ethically difficult care situations and of acute care work. The method of phenomenological-hermeneutic interpretation inspired by the French philosopher Paul Ricoeur was used. The most prominent feature was the focus on relationships, as expressed in concern for societys and administrators responsibility for health care and the care of older people. Other themes focus on how nurse managers respond to the ENs work as well as their relationships with fellow ENs, in both work situations and shared social and sports activities. Their reflections seem to show an expectation of care as expressed in their lived experiences and their desire for a particular level and quality of care for their own family members. A lack of time could lead to a bad conscience over the little bit extra being omitted. This lack of time could also lead to tiredness and even burnout, but the system did not allow for more time.

Introduction
Acute care is a specialized area in health care. It is one of the domains in hospital care where there is rapid development of new knowledge and new technologies, and in which care providers often feel uncertain about how to act.13 Care providers in acute units experience ethical problems when caring for their patients. They have problems with knowing what is the right and good thing to do, and they also face ethical challenges when caring for patients, such as how to interact with them and how to meet them in a good way. It is important to understand the meaning of the lived ethical challenges that

Address for correspondence: Venke Srlie, Institute of Nursing Science, University of Oslo, PO Box 1120 Blindern, N-0317 Oslo, Norway. E-mail: venke.sorlie@sykepleievit.uio.no

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care providers experience in acute nursing care units. To enlighten this difficult situation, care providers stories about their lived experience can be analysed. Brown et al.4 described differences in ethical perspectives when analysing stories about nurses experiences (i.e. focusing on care as opposed to focusing on justice). Previous research has shown differences in the experiences of being in ethically difficult care situations as related by health professionals. Udn et al.5 showed that registered nurses (RNs) and physicians working in internal medicine and oncology emphasized different matters when narrating ethically difficult care episodes: the RNs were concerned about the patients dignity, while the doctors were concerned about the patients survival. Studies have also shown differences between RNs working with various patient groups. In a hospital in Sweden, RNs working with cancer patients reasoned differently about feeding them when compared with RNs working with patients suffering from severe dementia. The former seemed more medically orientated than the latter.6,7 Stories told by RNs and enrolled nurses (ENs) working in surgical and geriatric care were analysed from a gender perspective. 8 No differences were shown for gender, but the ENs used narrative reasoning more often and showed a care orientation more frequently than RNs, who used principles and the notion of justice as well as a care orientation. The newly reorganized Swedish health care system has many challenges and it is therefore important to study how care providers in various care settings, including acute care units, narrate their experience of being in ethically difficult care situations. This study is part of a comprehensive investigation on the meaning of being cared for as well as the meaning of care as narrated by patients, RNs and ENs in an acute care unit. The aim of this study was to illuminate the experience of ENs being in ethically difficult care situations and on working in an acute care unit.

Method
Participants and setting
Five ENs aged between 45 and 62 years (mode = 60) who were working in an acute care unit at a university hospital in Sweden participated in the study. The total length of their care experience was 2442 years (mode = 36), and their experience in the acute unit was five years. The university hospital opened the acute unit in 1997, when these units were newly introduced into the Swedish health care system. The ward provides medical and nursing care, observation and treatment for a period of up to three days, during which time a decision has to be made regarding further care elsewhere, or a return home. The Ethics Committee of rebro University Hospital approved the study (no. 120/03). The ENs gave their informed consent to participation.

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Interviews
The first author conducted tape-recorded narrative interviews, which lasted for between 35 and 65 minutes (mode = 45) and were transcribed verbatim. Interviewees were asked to narrate care situations that they had experienced as being ethically difficult in their work. The aim was to understand the meaning of their experiences as they presented them. The concept of an ethically difficult situation was not defined, the question being left open for the respondents to identify what they themselves experienced as ethically difficult. Questions were asked only when the interviewer wanted the interviewees to elaborate their story or had difficulty in understanding the narration (e.g. what did you do, think or feel then?).9

Interpretation
The interviews were analysed and interpreted using a method inspired by Ricouer s phenomenological hermeneutics. 10 This method has been developed at the University of Troms and Ume University, and has previously been used by Lindseth et al.,11 Norberg and Udn,8 and Norberg et al.12 This method focuses on the meaning of peoples narrated lived experiences. The interpretation proceeds through dialectical movement between understanding and explanation. The first naive reading is a superficial reading of the text, to gain an overall impression and an initial grasp of the text as a whole. The naive reading shows the direction that the structural analysis of the text should take; this aims to explain what the text is saying. It includes examination of parts of the text in order to validate or refute the initial understanding obtained from the naive reading. The third phase the interpreted whole is an in-depth understanding based on the naive reading, the structural analysis and the authors pre-understanding. The interpreted whole is developed in the light of conceptual frameworks with the aim of gaining a deeper understanding of the text in its entirety. A naive reading was made of all the transcribed interviews to gain a first impression of the meaning of each text as a whole (i.e. the interviewees lived experience of being in ethically difficult situations during their clinical work as ENs). The repeat naive reading was carried out as open-mindedly as possible, without any deliberate attempt to analyse the text. In the next phase of structural analysis, the interviews were divided into meaning units (i.e. a sentence, parts of a sentence or a whole paragraph with a related meaning content). The meaning units were discussed among the authors and condensed, and themes and subthemes were identified. Finally, a critical comprehensive understanding was developed, taking into account the authors pre-understanding, the naive reading and the structural analysis. The text was read as a whole and understood in relation to theory and investigations into the meaning of being in ethically difficult care situations, leading to the formulation of a comprehensive understanding.

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Results
Naive reading
The naive reading revealed that the most prominent feature of the narratives was the focus on relationships, as expressed in concern for societys responsibility for health care and the care of elderly people. Other recurrent themes were how nurse managers responded to their work, and their relationships with their fellow ENs, in both work situations and outside social and sports activities. Reflections regarding patients were limited, seeming to show a lack of professional expectations of care, but care was expressed in lived experiences and the desire for particular levels and quality of care for their own family. A lack of time could lead to a bad conscience because of the little bit extra being omitted, despite the recognition that this was important for both parties. This lack of time could result in tiredness and even burnout, but the system did not allow for more time.

Structural analysis
The themes and subthemes formulated are given in Table 1. Societys and administrators responsibility for health care services Changes in the health care system: The ENs emphasis and focus was on a health service that has declined in quality: Its not a good thing to land up in a hospital now. There is increased pressure on personnel and an increase in patient numbers in all health care institutions. There are more older people who have individual needs for care of greater complexity. Some elderly patients who require places in long-stay institutions are sent to an acute care facility. This all emphasizes the feeling that hospitalization should be avoided owing to the lack of resources. The responsibility of society is seen to be embodied in the local community, but this responsibility is not fulfilled: There is a distinct lack of human resources, such as doctors and nurses, in the community. The community does not care for its elderly people. The decline in the quality of health care in the community is also due to the Table 1 Overview of themes and subthemes formulated in the structural analysis of interviews with ENs Theme Societys and administrators responsibility for health care services Confirmation from nurse managers Positive work environment Content of the concept of care Role of conscience Challenges on the ward Challenges among colleagues Subtheme Changes in the health care system Limitations on the ward

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employment of younger, less experienced nursing staff. There is a lack of resources elsewhere in primary health care, which, together with exhausted relatives, results in patients contacting the acute care institutions directly. Limitations on the ward: The ward is under continuous pressure because of the short duration of patients stay and the considerable number of patients being admitted and discharged daily. The weekends are the worst time for both staff and patients because staff numbers are reduced at these times. Those on duty have insufficient time to keep abreast of events and to listen to patients, while not leaving them unattended. The ward serves as a buffer zone for the hospital, having to admit those for whom this accommodation is not suitable, such as patients with dementia. This leads to a lack of beds for patients who should rightfully be admitted to the ward, confirming its function as a diagnostic unit: We dont have enough room for patients who are in need of care. They get sent home again. Confirmation from nurse managers Managers are no longer distant figures of authority. The nurse managers selected the ENs from other wards when the acute ward was opened five years ago. This gave the ENs the feeling of being confirmed as important and needed on the new ward. The managers are people who listen to the ENs, can be spoken to by them and confided in. At the same time, they demonstrate their confidence in the ENs by being open in their communication with them. ENs are not afraid of bringing problems to the nurse managers attention. The managers trust the ENs: We have very good managers who see us as we are. They listen to us and speak freely with us. They trust us. Confirmation was stated to be appreciated when it comes from doctors. This can be in the form of appreciation of ENs knowledge and initiative, but more informal confirmation was also mentioned, occurring during coffee breaks and in light-hearted communication. Positive work environment Challenges on the ward: A positive work environment is important for these ENs. They noted that it is important to have good colleagues as well as good nurse managers directing the ward: Its great that we are open with one another. The ENs reported that they consider it a positive challenge that there is not a fixed routine on the ward, that unexpected events are also part of the working day: I like the flexibility of the ward, and being able to be flexible myself, in what I do there. Flexibility is combined with responsibility and independence for these ENs. The variety provided by the patients means that the ENs are constantly learning something new. Training aimed at assisting them in relationships with patients was noted to be appreciated: I look forward to going to work. I enjoy working in health care. Challenges among colleagues: The ENs on the ward said that they like their colleagues. It is important that they can talk to one another, support each other, and agree with each other: Its great to be able to talk freely to one another. My work environment means a lot to me. They also believe it is important that the ENs

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enjoy working together and can laugh together. The ENs also enjoy one anothers company outside the ward. They play handball and go cycling together, and even have a spring outing. Content of the concept of care The concept of care was defined by the ENs in terms relating to their practical experience in caring situations, as well as their desire for adequate care for their own relatives. Time, or rather the lack of it, was an important focus for the ENs reflections on care: The patients feel safer when we say that we will be coming back to them soon. This makes them happy and satisfied. They seldom complain. The ENs recognize, however, that returning to patients is highly unlikely in practice. This is unsatisfying for them. The patients see that the ENs are under considerable pressure and must always hurry on to the next task. The patients want to talk to the ENs, but the ENs just do not have the time available. The patients are seen to be forgotten in a corner, left to their own devices, having been incontinent and not being turned as often as necessary: We dont have time to give priority to patients who need this sort of care. We are very abrupt when talking to our patients, and demonstrate very clearly that we dont have the time to talk to them. We dont have the time to care for them or to help them. The ENs consider that this indicates to the patients that they are uncaring. The ENs are aware that the practical tasks are performed, but nevertheless that they are insufficiently caring towards the patients and that they frequently talk about this to their families. Imagine if this was to happen to one of my family. They define care in terms of their desires for their own closest family. This becomes the standard of care against which they evaluate their practical caring experiences. Role of conscience The recognition that they are unable to meet these standards of care then results in dilemmas of conscience for the ENs: We are split into two as human beings. In part, the ENs accept that what they actually do is adequate, but also partly recognize that this is not up to the standard they wish to meet: The best care is the care I would want my own mother to receive. The ENs note that it is that little bit extra that is a problem for their consciences: not having the time to wash patients hair, or to hold their hand for a while.
Wouldnt it be great to come home and feel that I had really been kind today. To have done that little bit more that would be really fantastic. It isnt really a lot to do, but it means so much for me as well as my patient. It gives me an inner satisfaction.

The bad conscience increases for the ENs when they acknowledge that they were unable to do that little bit extra. It leads to headaches, other physical pains, and even to exhaustion. I seem to have aches and pains in my body, but the pain is really in my soul, my conscience. The pain I feel is my conscience. The ENs continue apparently unchanged by their qualms of conscience. They do, however, recognize that they become increasingly tired and that burnout can result from this:

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Its not easy to cut out all my thoughts about things that werent good enough during the day. My thoughts go round and round in my head all night. If I dont cut these thoughts out somehow, Ill get tired. I have to force myself to think about something else.

The ENs (n = 10) selected in 1997 are still working in the unit, despite the above. The interviewees underlined that 50% of the RNs selected at the same time have moved to other units. The confirmation that the ENs have received from the nurse managers and doctors, together with the very positive environment they enjoy with their colleagues at work and when off duty, has given them a firm basis for their work. None of them has experienced burnout: The responsibility for health care and care of the elderly population is in the hands of the authorities (i.e. society and administrators). We have to accept that its extremely busy here. Its just not possible, given the time and resources we have available to us, to do our best.

Comprehensive understanding
The results demonstrate clearly that, while interviewing the ENs about ethically difficult situations, they volunteered a considerable amount of information about the positive factors they experienced in those same situations. According to Lgstrup19 interviewees can indirectly shed light on what is good in their experiences when asking them about ethical challenges in acute care work. Given the interviewees age (mode = 60 years) and length of experience (mode = 36 years) it does not seem unreasonable that they have had both the time and the opportunities to reflect on the many aspects of their work and the ethical challenges they meet. This has become part of their own way of resolving these challenges. The ENs participating in this study seem to have placed the ultimate responsibility for their overall situation at their place of work with the authorities (society and administrators), and the system in which they work. They are very explicit about the problem of lack of resources, which they see to be worsening over time. They are equally explicit about their own lack of power to change this situation. The fact that they are all older and more experienced ENs has possibly helped them to accept the lack of resources for what it is: a political question over which they have little or no control. Lack of resources in health care can be a real problem for society. This is closely related to the policies governing priorities defined by national leaders. Ethics is related to people and to actions. Sometimes we refer not only to unethical actions and unethical people, but also to an unethical order in society and maybe even an unethical society. An unethical society is not one where certain actions are unethical but rather a society that is organized in an unethical manner, leading to a systematic and continual breakdown of all that is right and just. An unethical society makes it extremely difficult for people to act in an ethical way, even if they wish to do so. It can also be said that certain regulations in a society are unethical. This can apply to sickness benefits, immigration policies, or employment and wages systems in health care, for instance. Ethics can be discussed from three different points of view, depending on whether we wish to emphasize actions, people or society.13 The ENs focused heavily on ethical challenges from a societal point of view.

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The ENs are, however, dependent on other sources to provide them with a sense of worth and well-being in their work. They emphasize the positive role of their nurse managers and the doctors in confirming their professional competence. These are people who would give clear indications of their shortcomings if they considered that the ENs were falling short of performance requirements at work. This confidence in the ENs work seems crucial to their acceptance of the situation as it is. The enrolled nurses stress that being confirmed as good ENs by managers, doctors and RNs is important for them. To be confirmed is to be seen, listened to and accepted by another person.1416 A persons identity is dependent on another person in a good or bad relationship, as well as on a voice from within the person, her or his conscience. Confirmation is about both social confirmation from another person and self-confirmation from ones own conscience.3 The close working environment provided by their immediate colleagues is also very important. The fellowship that they provide for one another, not only at work but also in social and sporting contexts outside of their place of work, also seems to give them strength and self-assurance that reflects on them as individuals as well as professionals. This is consistent with Lgstrups concept of the interdependence between individuals:
A lot can be suffered, a passing atmosphere, a good mood, that we let fade away or that we awaken, an influence that we investigate further or discard. But it can also be something so important that it is no longer up to the individual whether the others life succeeds or not.17

The ENs define care and acceptable levels of care in terms of practical experiences and desires. Their formal training does not provide them with ready-made definitions of what they should do. This appears to be an advantage in that they do not seem to feel the responsibility for the quantity and quality of care given as may otherwise be the case. They see very clearly that the reason for not meeting their own personal standards for care are not in their hands, but rather in the hands of the authorities that determine the level and amount of resources available on the ward. This enables the ENs to recognize the problems of conscience relating to levels of care not being given, while not accepting responsibility for the situation in which they find themselves. It does not, however, free them from some of the pain and exhaustion they themselves feel: . . . the voice of conscience tells me that all other life is as important as my own.18 The responsibility is placed externally, on society in the form of the local community and authorities. This external placement of responsibility is quite possibly a direct cause of the lack of turnover in the workforce, and the lack of burnout among the ENs. Such external placement is known to protect against the physical manifestations of stress that may otherwise be the outcome of the qualms of conscience recognized by the ENs. As experienced ENs they know that similar situations on other wards and in other institutions are also determined to a great extent by the same societal constraints. They are therefore unlikely to experience an improvement by moving to another, similar place of work. The positive confirmation from others, and the generally positive work environment are factors that are not necessarily the same

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in other places of work. These two factors could therefore explain the apparent lack of mobility of these ENs. In total, therefore, the ENs are content to remain where they are and to make the most of their situation. Diverse ethical demands by various health care professionals arise from different levels of care given. Nursing acute care patients poses a challenge to ENs because it invites them to evaluate critically both personal and professional issues to decide what may be the best options for themselves and for the patients.

Methodological considerations
The purpose of the interviews was to obtain as many rich narratives as possible about ENs being in ethically difficult care situations without interrupting their narrative flow and reflection. In an interview where the focus is on difficulties, indirect light may be shed on what a good life is or what the good is by talking about what is missing or is at stake.19 Narrative interviews disclose possibilities for interviewees to talk about what is important to them. Thus it is an important way of obtaining information about the meaning of the lived experiences of ENs in particular situations.20 According to Vitz21 and Ellos,22 analysing narratives about lived experience is a useful method of providing new insights. A kind of validation is performed by the structural analyses, the objective part of the interpretation process.10 To answer the research question, narrative interviews interpreted by using a phenomenologicalhermeneutic approach seemed to be a useful choice for this study, which reveals the possibilities of interpreting lived experiences and provides a basis for reflection and discussion about the meaning of being in ethically difficult care situations. The results of this study cannot be generalized, but they are credible if people with similar experiences can recognize the descriptions or the interpretations as their own,23 and if these can be transferred into similar situations.10 The interpretation of this phenomenological-hermeneutical investigation can, as Ricoeur says, be argued for or against, and is only one of several possible interpretations.10 Comprehensive understanding in this context can at best provide recognition or a deeper and different understanding of the meaning of being in ethically difficult care situations.

Acknowledgements
The authors are grateful to the participants in the study, to co-worker Anita Ross, and to Ms Jill Almvang for revising the English. Venke Srlie, rebro University Hospital, Sweden, and University of Oslo, Norway. Annica Larsson Kihlgren and Mona Kihlgren, rebro University Hospital, Sweden.

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