Ethical dilemmas and burnout in nursing practice

Ethical Dilemma -- Life Issues

What are the most common ethical issues that nurses face? There is ample literature on the stressors placed on nurses in the field today, and some of them can lead to ethical dilemmas -- but which ones, and how do nurses respond to these ethical dilemmas? What is the proper direction to turn for a nurse that is being confronted with moral distress? How does ethical reasoning help a competent, professional nurse get through the moral and ethical dilemmas with reference to his or her duties and responsibilities? These matters and others will be addressed in this paper.

What Ethical Dilemma?

First of all it should be pointed out that while engaged in their daily duties, nurses are frequently confronted with ethical issues, which are often dilemmas. A research project by Raines (2000) showed that over a one-year period, on average, oncology nurses are faced with up to 32 "different types of ethical dilemmas… with many of these events taking place daily" (de Casterle, et al., 2008, 540). And given the emerging complexity of healthcare in general and medical technological advances in particular -- and the "…lack of evidence-based interventions" -- nurses are called upon near-constantly to reflect on how to make their patient's well-being their top priority, which calls for a "high-level professional competence and ethical maturity" (de Casterle, 541).

That having been said, de Casterle goes on to assert that many if not "most" nurses seem to be "ill-prepared to address ethical dilemmas" (541). A research paper by Botes (2000) revealed that nurses often do not "think critically" when they are up against ethical decisions, according to de Casterle's paper (541). Moreover, other studies reflect a variety of situations that "conflicted with their ethical values" and during which they were expected to "implement actions that they perceived as ethically wrong" but they did not do so (de Casterle, 541). Nurses have indicated (Turner, et al., 1996) that it is "virtually impossible to practice according to one's own ethical values or to voice ethical problems within the team" (de Casterle, 541).

The Ethical Dilemma -- Created by Burnout

In addition to all the stressors that nurses face in their daily work routines -- workload, relationships with other clinical staff, management and leadership issues, the perceived lack of reward, "emotional demands of caring," and shift changes -- the salient issue that can lead to ethical dilemmas is burnout (Wlodarczyk, et al., 2011, p. 847). According to Wlodarczyk, very few studies consider the role of ethical conflicts vis-a-vis burnout. According to the research in the Wlodarczyk paper, burnout is a state of "…physical, emotional and mental exhaustion" that is the result of "long-term involvement in work situations that are emotionally demanding" (848). Part of the reason burnout becomes a challenge for nurses is that these professional individuals attempt to "…reach unrealistic goals" but they wind up "depleting their energy and losing touch with themselves and others" (Wlodarczyk, 848).

The author is alluding to more than just physical fatigue in this context; Wlodarczyk is specifically describing the "depersonalization and reduced personal accomplishment" -- along with emotional exhaustion -- that causes burnout. The depersonalization in this regard leads to a lowering of one's "feeling of competence" and it also leads to a sense of being unable to cope with the demands that nursing brings. As the quality of a nurse's work lowers (due to burnout), ethical dilemmas arise, the authors report.

The burnout situation gives rise to these ethical issues: a) moral distress (that happens when a nurse can no longer handle the morally responsible actions); b) moral dilemma (this happens when two or more "moral principles apply but they support mutually precluding courses of action); and c) moral uncertainty (not knowing which of the moral principles or values are applicable to a given nursing situation) (Wlodarczyk, 848). On page 856 Wlodarczyk points to the ethical conflicts that are related to burnout: a) no longer able to "maintain a proper attitude towards an impolite patient"; b) involved in an "inappropriate interpersonal relationship" with another nurse; c) witnessing a nurse discrediting another nurse in the presence of a third party; d) lack of colleagues' understanding in situations that relate to professional qualifications" e) the inability to keep a proper professional attitude toward one's patient due to "task overload"; and f) witnessing an "unfair and ungrounded critique" of a nursing colleague (Wlodarczyk, 856).

The Implications from an Advanced Practice Nurse's Perspective

The initial response to conducting the research on nurses, burnout, ethical dilemmas and moral distress is that healthcare administrators, educators and executives have fallen down on the job in terms of preparing nurses for a stressful position in the workforce that can't help but create high levels of stress, based on the information and data previously presented in this paper. Another peer-reviewed article in Nursing Ethics points to the research that shows moral distress is "similar to burnout," which is defined by Ohnishi as "…an excessive stress reaction to one's occupational or professional environment" (Ohnishi, et al., 2010, p. 728).

From the perspective of the psychiatric nursing milieu in Japan -- using the MBI-General Survey (MBI-GS) scale, which is employed as a way to measure burnout -- the three subscales of burnout are "exhaustion, cynicism, and professional efficacy" (Ohnishi, 728). Exhaustion occurs first, and then it evolves into cynicism, and finally into professional efficacy, Ohnishi explains (728).

Ethical Reasoning Perspective

In the first place it is difficult for a nurse or other professional in the medical and healthcare field to embrace ethical reasoning if he or she is suffering from burnout that takes a moral toll on the individual. The role of ethical reasoning is to bring special attention to two kinds of human actions: a) those that are beneficial for the well being of others (that deserves praise from observers); and b) those human actions that harm others or diminish the well-being of others in some way. Are competent, respected nurses capable of fully embracing ethical reasoning if their own moral standards are being whittled away by the stress of the job and by the subsequent onslaught of burnout? The answer from this paper's perspective is no. In fact asking a nurse that has suffered from burnout -- the accumulation of stress from all the challenges mentioned in this paper -- to competently, intelligently perform ethical reasoning practices is difficult at best and folly at the worst end of the spectrum.