From Suffering to Indifference: Reaction of Novice Nurses to Ethical Challenges in First Year of Clinical Practice.

BACKGROUND: The first year of clinical practice is one of the most important steps in nursing career life. Although, studies have been conducted on ethical issues in nurses, however, few studies have been conducted on the responses of novice nurses to ethical issues. The purpose of this study was to explore the responses of novice nurses to ethical challenges in the first year of clinical practice.
MATERIALS AND METHODS: This study is a qualitative study with content analysis approach was conducted with financial support of Arak University of Medical Sciences. In this study, about 11 novice nurses selected using purposive sampling from educational hospitals affiliated to Arak University of Medical Sciences. Data were collected by semi-structured interviews. The duration of the interviews was 30-110 minutes. In order to analyze the data, inductive content analysis was used.
RESULTS: Data analysis revealed two important, and different responses over time in novice nurses. So that at the beginning of practice, the reaction to ethical challenges was "suffering" and after a few months it became "indifference".
CONCLUSIONS: This study showed that the response of novice nurses to ethical challenges in the first year of clinical practice was a transition from suffering to indifference. These findings can be used in nursing education, research and practice. Further research is recommended in this regard.

Introduction

Nursing is a unique, multidimensional, and complex relationship between the nurse and the patient. Provision of the personal needs of the patients is the pillar of nursing care, and the ultimate goal of nursing is high quality patient care.[12] In fact, receiving quality care is the right of every patient, and its fulfillment is duty of every caregiver.[34] Nurses frequently face ethical challenges in the work environment.[5] These ethical challenges are one of the major challenges affecting novice nurses.[6] Technological advances, and new technologies have revolutionized the care for seriously ill patients, resulting in the emergence of numerous ethical challenges in patient care.[1] Issues like care for comatose patients, Do Not Resuscitate Order (DNR), abortion, care for end-stage patients, and physical restraint of patientsare among these challenges.[7] The nurses should make ethical decisions and defend their patients’ rights. Also there may be cases of violations on nurses’ rights, in the clinical workplace. All these factors create ethical challenges for nurses, especially novice ones.[1] Cultural, political, and socioeconomic factors also affect these challenges.[7] Inequity in access to health services, insufficient allocation of resources, and nursing personnel shortage contribute to these ethical challenges in the clinical environment.[8]

The unethical behaviors, and attitudes of the nurses and physicians sometimes worsen ethical Issus. Moreover, variables like personality traits, culture, lack of moral sensitivity, restriction of the patient's independence, and dissatisfaction with work conditions may affect the clinical nurses’ decisions and moral performance.[789] The novice nurse has no experience in the situations in which they are expected to perform.[10] Novice nurses face numerous ethical challenges when they first enter the clinical environment. These challenges create a threatening situation for novice nurses and may cause tension at the beginning of their career.[1112] In this regard, several studies have shown that inadequate moral knowledge and sensitivity in deal of these challenges have many negative consequences and may lead to adverse physical and mental reactions like anxiety, fatigue, and job dissatisfaction.[13]

A study showed that nurses are not prepared to meet these challenges when they begin clinical work.[13] They have to deliver safe, competent, and ethical care to their patients. The way they respond to these ethical challenges depends on cultural, organizational, and personal factors.[7] Understanding the experiences and reactions of novice nurses to these challenges is very important, and can help managers to plan for the promotion of nurses’ moral knowledge, ethical sensitivity and minimizing their moral distress, as well as improving the ethical climate of the clinical workplace. Hence, the present study was conducted to explore the reactions of novice nurses to ethical challenges in their first year of clinical work.

Materials and Methods

This study is a qualitative research with content analysis approach which is an appropriate method to discover the experiences and reactions,[1415] according to Consolidated criteria for Reporting Qualitative research (COREQ) Checklist/guideline. This study was conducted on nurses working in educational hospitals affiliated with Arak University of Medical Sciences from March 2017 to February 2018. About 11 novice nurses working in different wards of the educational hospitals were selected using purposive sampling with maximum variation. Inclusion criteria include: work experience less than one year, lack of work experience during the student course, intend to participation in the study. In order to have maximum variation, sampling was done from different hospitals, wards and working shifts. Semi-structured in-depth interviews were used to collect the required data. Interviews were conducted by the first author with master's degree in nursing. Initially, the researcher introduced the purpose of the study to participants.

At first, an overall question was asked: “tell me about the ethical issues in your clinical work”. Then, based on the mentioned materials, more specific questions were asked to explore their reactions to these ethical challenges, problems, and difficulties. Such as “what were you doing, when did you encounter with these challenges?” The experiences of the participants were recorded during the interview and transcribed verbatim and analyzed after that interviews were finished. The duration of the interviews was 30-110 minutes. In addition, field notes were used to construct thick, deep and rich descriptions of nurses’ experiences in this study. Field notes were written by the researcher during or after each interview. They included information on the participants’ statements, the context of study, and researcher's thoughts on the obtained data.[16] Data collection continued until theoretical saturation was achieved and no new findings were revealed.[16] In this study there were about 16 interviews were done. Meanwhile, based on the emerging data, and in order to provide a clear picture of the experiences of the novice nurses, complementary interviews were used, so some participants were interviewed twice (n = 6). The deductive content analysis method to create concepts and categories proposed by Graneheim and Lundman (2004) was applied.[14] In this method, after each interview, the recorded data was heard carefully, then transcribed and encoded. Then meaning units were extracted. These meaning units are categorized based on similarities in groups. Then, common concepts were considered as themes.

Credibility was ensured by means of prolonged engagement with participants, spending sufficient time on data collection and analysis, and member check.[17] To confirm transferability, the researcher provided a rich analytical description of the context, methodology, limitations and maximum variation of sampling.[1819] Dependability was established through auditing. The data and documents were meticulously checked by two researchers and a number of assistants. The list of extracted codes and categories were given to two researchers and several colleagues and they were requested to review them and then, according to their comments, the categories were modified.[18] To enhance conformability, the records of the research steps taken from the start of the research project to the development and reporting of the findings were kept throughout the study so that to help other researchers who decide to conduct a similar study in this field.[19]

Ethical considerations

This study was approved by the Research Deputy and Ethics Committee of Arak University of Medical Sciences and related hospital authorities [Ethics code: IR.ARAKMU.REC.1397.4]. Verbal Informed consent forms were obtained from all participants.

Results

In this study, about 11 novice nurses who were in their first year of clinical work participated. Their mean age was 25.61 years. Also 72.74% of them were women and 63.69% were single [Table 1]. Data analysis and interpretation of the results showed that reaction of novice nurses to ethical challenges in the beginning of clinical work was “suffering”, which gradually transformed to “indifference” over time. Table 2 presents the main categories and their subcategories.

Table 1

Socio-demographic characteristics of participants

Participants Number	Age (year)	Gender		Marital status		Work experiences (month)	Unit
		Male	Female	Single	Married
1	26		×	×		9	Surgical
2	27		×	×		11	Surgical
3	23		×	×		3	Orthopedic
4	28		×		×	5	Neurology
5	25		×	×		5	Heart emergency
6	25		×		×	4	Orthopedic
7	28	×		×		6	Infectious
8	26	×		×		7	Heart-lung
9	24		×		×	5	Oncology
10	27		×		×	8	Neurosurgery
11	23	×		×		6	Orthopedic

Table 2

The codes, main themes and sub-themes of reaction of novice nurses to ethical challenges in first year of clinical work

Codes	Sub-themes	Themes
Lack of sufficient skill	Suffering from self	Suffering
Inability to make decisions
Lack of confidence
Abusive behaviors of colleagues	Suffering from others
Experience insulting and offensive
The patient’s violence against the nurse
Head nurse’s injustice in assignment
Ignoring patient’s rights	Suffering from conditions
Inappropriate behavior of the health team with the patient
Hide diagnosis from the patient
Lack of proper education to the patient
Reduced sensitivity to ethical issues	Fading of professional commitment
Get used to the situation	Getting used others’ behaviors	Indifference
Normalizing bad behaviors of others
Adapting to environmental conditions	Indifference to the situation
Lack of respect for the human rights of patients
Disregard for patients and their rights

Suffering

Analysis of the interviews showed that at the beginning of clinical work, the reaction of novice nurses to ethical challenges was “suffering”. This suffering had a high intensity, was either overt or covert, and was not similar in all nurses. Personal characteristics of the nurses and the characteristics of the work environment affected this reaction. This category had three subcategories of “self-suffering”, “suffering from others”, and “suffering from the conditions.”

Self-suffering

Almost all nurses mentioned suffering from self in exposure to ethical challenges at the beginning of work. They had a negative assessment of their capabilities at the beginning of work, which caused them a great deal of suffering. This suffering was related to their incapability to communicate with critical patients and their families. This negative feeling was a reason for suffering. The nurse 5 said, “In the beginning I could not communicate with cancer patients or grieving families. It was really a torment to me.”

Participant 7 said, “I would like to apply the principles of ethics in clinical work. Patient rights are very important to me. I want them to make decisions, but I do not know what to do. I do not know what is correct. They have not taught us these things! It is very painful.”

Suffering from others

This subcategory included suffering from others’ suffer and suffering from others’ behaviors'. Close contact with patients and their families as well as exposure to comatose patients, end-stage terminally ill patients, complex situations, brain death, organ transplantation, etc., were the sources of this suffering. Sometimes socioeconomic inequalities like poverty, economic problems, etc., caused this reaction. In this regard, nurse 10 said, “When I see a patient has a bad condition, and nurses do not take care of him/her well, I'm very upset for several days. It is very painful.”

Suffering from others’ behaviors included suffering from inappropriate behaviors of other nurses, patients and their families. Insult, verbal assault, violence, and aggression were common experiences in novice nurses. In this regard, nurse 1 said, “The nurses’ rights are often violated. Some patients’ relatives insult us.”

There were some injustices in patients care. The nurse 10 said, that “distribution of resources is not the same for all patients and some patients do not receive proper care.” Head-nurse discrimination between a novice nurse and other colleagues led to her/his suffering.

Suffering from conditions

Sometimes facing ethical challenges in the work environment caused painful situations for novice nurses. Problems like violation of patient privacy, inappropriate behavior of the health care team with the patient, hiding the real diagnosis from the patient, lack of proper education and refusal to involve the patient in treatment decisions were mentioned by the participants. The patient's family requested novice nurses to withhold the real diagnosis from the patient for different reasons. The nurses did not really know what to do in this situation and were confused and bewildered. Withholding the diagnosis or lying about it was a source of a guilty conscience for novice nurses. Nurse 9 said, “Sometimes the family members of a patient ask me not disclose the diagnosis of cancer and tell the patient that it is an infection that can be treated with a new antibiotic. They even ask me to tell a lie about chemotherapy. It is very difficult for me to lie.”

Indifference

Analysis of the interviews showed that after a while, the reaction of novice nurses changed from “suffering” to “indifference”. However, this reaction was subjected to the nurses’ personal and work environment characteristics, and could range from mild to severe indifference. This reaction included three subcategories of “fading of professional commitment”, “getting used to others’ behaviors”, and “indifference to conditions”.

Fading of professional commitment

The participants stated that their sensitivity decreased over time and their professional commitment gradually faded as they saw the behavior of experienced nurses. The reason for fading professional commitment was difficult working conditions and long working hours. In this regard, nurse 2 said, “I was very diligent in the beginning. However, after a while, I could not keep on like that. I really got tired. It was impossible. So I became like my co-workers.”

Getting used others’ behaviors

This subcategory included getting used to the patients’ sufferings and conditions and others’ behaviors. The data showed that some months after starting clinical work, the novice nurses were accustomed to the patients’ suffering and the inappropriate behaviors of people in the workplace. Nurse 3 said, “In the beginning, when I saw that the rights of a patient was denied treated with disrespect, I became very upset and became preoccupied for a long time, but I got used to them after a while.”

Regarding getting used to inequalities and discriminations in the work environment, nurse 2 said, “discrimination is very common; “Here, discrimination between us and other nurses is commonplace. These injustices have become commonplace to me.”

Indifference to the situation

The results showed that after a while, novice nurses became indifferent towards violation of moralities, patient rights and immoral behaviors. They developed some sort of indifference, insensibility, and apathy towards observing ethical principles and patient rights because of high workload and difficult working conditions. In this regard, a novice nurse 1 said, “I observed patient rights in the beginning. I was careful with patient education, respect for patient privacy, but I saw no one did them. So I do not care anymore.”

Discussion

The results showed that novice nurses experienced a lot of suffering in the beginning of clinical work, but this suffering was replaced with indifference after getting used to the conditions. Moreover, at the beginning of the work, the novice nurses had tended to utilize what they had learned about ethical issues. They were committed to respect the patients’ rights. However, because they were not capable of doing so in the real clinical setting, they experienced intense emotions.

”Suffering” was one of the concepts revealed in this study, which included “suffering from self”, “suffering from others”, and “suffering from conditions”. In line with our results, stress, anxiety, fatigue, and many problems was a common experience for novice nurses in the first months of clinical practice. Many of these reported problems are similar to those found in the current study. The sources of this problems were unpreparedness for clinical work, hard working conditions, and behaviors of other nurses.[7] The results of the present study showed that other people, including patients, their families, and other nurses, can be a source of suffering for novice nurses. For example, Incurable medical diagnoses, chronic difficult diseases, and painful procedures were some of these factors. Other studies have also reported that nurses suffer when they witness their patients’ sufferings.[618] Our results showed that difficult decision-making conditions, the fair distribution of resources and moral dilemmas were other sources of suffering in novice nurses. In this regard, some studies have reported that Nurses’ exposure to ethical issues in the clinical setting is very stressful and can lead to turnover. Also, reducing working hours and colleagues’ support of novice nurses may reduce the negative consequences. Our findings showed that after a while, the reaction of the novice nurses changed from “suffering” to “indifference” that manifested as “fading of professional commitment”, “getting used to others’ behaviors”, and “indifference to the situation”. One study showed that novice nurses tried to adapt to working conditions and sought to cope with the situation.[19] According socialization theory, individuals learn required roles from each other's. So the novice nurses in this study learn abusive behaviors from other nurses.[16] Some studies have mentioned factors like learning the inappropriate behaviors of colleagues. Group solidarity, and Sense of belonging to the team, which is rather consistent with our results.[2021] According to Ohnishi et al., nurses experience less moral distress as their knowledge and skills improve.[22]

The study by Andersons and Edberg showed that at the end of the first year, novice nurses felt a sense of empowerment, competence and self-esteem. Also, the feeling of insecurity and initial confusion were replaced with a sense of security and confidence. The acquisition of professional identity was the ultimate outcome. Many of results of their study are also consistent with our study.[10] The authors explained that all novice nurses pass through these stages, and along this path, learn how to control and manage unexpected events.[10] Many findings of this study are consistent with our results. Since our study had a qualitative design, it has limitations in transferability of these results. However, we tried to overcome these limitations and enhance its transferability through, maximum variation sampling, and thick description of all concepts. This study as a qualitative research has the limitations. These can be mentioned as the lack generalizability of the results to other populations due to using purposive sampling. Also, the finding of this study should be used with caution. So, it seems necessary to do more qualitative and quantitative research in this field. In general, the findings of this study showed that the reaction of novice nurses to ethical challenges in the first year of clinical work gradually transformed from “suffering” to “indifference”. Although this pattern was observed in all novice nurses, its nature was different depending on the colleague's characteristics and contextual factors, i.e. it was unique in every nurse.

Conclusion

According to the findings, the reaction of novice nurses to ethical challenges in the first year of clinical work showed a transition from suffering to indifference. It seems that contextual factors and behaviors of their co-workers can be affective on this pattern. The results of this study can be used as a guide to design supportive and educational programs for novice nurses. These findings can also be used by nursing managers and stakeholders to develop and expand educational objectives in order to enhance ethical atmosphere of clinical workplace and moral sensitivity of nurses.

Financial support and sponsorship

Arak University of Medical Sciences

Conflicts of interest

Nothing to declare.