Strategies and challenges in addressing ethical issues in the hospital context: A phenomenological study of nurse team leaders

Overview of Nursing Care Delivery Models in Indonesia

In Indonesia, the nursing delivery model used in inpatient departments generally follows the person-centered care method (Juanamasta et al., 2021b). The patient-centered care method has three models: individual, team, and primary care (Parreira et al., 2021), and the model depends on the unit type and the number of beds. However, most hospitals in Indonesia use the team delivery model (Juanamasta et al., 2021a). Therefore, the role of the team leader is emphasized as they are responsible for decision-making during each shift, including complex, ethical, and interprofessional healthcare and patient issues (Arisanti et al., 2018).

A hierarchical reporting model is applied when reporting problems (Figure 1). Staff nurses, also known as associate nurses or “Perawat Pelaksana” in Bahasa Indonesia, report to the nurse team leader or nurse shift coordinator, also known as “Ketua Tim” in Bahasa Indonesia. The nurse team leader then consults with the head nurse and continues to escalate the problem to upper management if it cannot be solved (Gunawan & Juanamasta, 2022).

Head nurses or head wards/units typically work only during the morning shift. Staff nurses can consult with them if there are any problems. Unfortunately, they are not present during the afternoon and night shifts, during which the nurse team leaders handle most issues. A previous study found that the afternoon and night shifts increase the number of miscarriages (Bonde et al., 2013). Therefore, the essential role of the nurse team leader in dealing with ethical challenges should be considered.

Study Design

Hermeneutic phenomenology was used for this study to explore the experiences of nurse team leaders when dealing with ethical issues (Spence, 2017; Todres & Wheeler, 2001). The aim of phenomenology is to understand the human experience by interpreting the phenomena encountered daily. Specifically, Heidegger's philosophical approach is used in this study, which emphasizes that a person’s “being” in time shapes their interpretation of experiences. Heidegger's concept of Dasein, which refers to how humans live their lives, is essential in reflecting on the existence (Todres & Wheeler, 2001). Humans engage in inter-subjectivity, a subjective encounter with the objective elements of the world, to reflect on their existence, which is consistent with the concept of Dasein. This study's philosophical approach comes closer to one's life world and the setting of their regular contacts (Lamb et al., 2019), which is critical in understanding the experiences of nurse team leaders.

Participants

The respondents were selected from seven hospitals (three public and four private hospitals) in Indonesia. Specifically, the participants were nurse team leaders who met the inclusion criteria: clinical nurses currently working in an inpatient environment, having experience as a nurse team leader, and having reported at least one ethical case problem within 90 days prior to the start of the study (1 November 2021– 28 February 2022). Due to the limited information on nurse team leaders who had previously faced ethical issues, the participants were recruited using a snowball sampling technique. During the process, sixteen nurses refused to provide information for various reasons, such as discomfort with the topic, concern about its impact, feeling unsafe, and busy working conditions. Finally, 14 registered nurses (RNs) were included. The number of participants was decided when data reached saturation, or no new codes were extracted. It is noted that the researchers analyzed the data after each interview.

Data Collection

Interviews were conducted based on the nurse’s time and place. Online interviews were preferred using video conferencing tools like Zoom or Google Meet and social media platforms like WhatsApp, Line, and Messenger due to the COVID-19 pandemic (Gunawan et al., 2022). This study used Bahasa Indonesia for interviews, analysis, and interpretation. The lead author interviewed each participant for approximately an hour, mostly in the hospital’s conference room after their shifts were over. Semi-structured interview guideline was prepared, and the opening question was, “Please tell me about nursing ethical issues.” The interviews were dialogical, with a special focus on the strategies and challenges faced by the nurse team leaders to deal with ethical problems. Answers to the primary question guided the interviewer to ask other exploratory questions concerning the nurse team leader’s strategies and challenges to facing ethical dilemmas by asking, “Can you tell me more?” “Can you give an example?”

The research team had four members: the lead investigator, one researcher, one research team member with managerial responsibilities or supervision of nurses, and one member directly tied to the study organization. The research team members used online meetings to track the study’s progress and conclusions. All members have experience in nursing research. No repeated interviews in this study, and it is noted that there was no relationship between researchers and participants that might influence the responses.

Data Analysis

The researchers utilized Van Manen’s approach (Van Manen, 2016) to analyze the data, which provides four levels of analysis that help to gain a more profound understanding of the significance of the living experience of the individuals being studied. These four levels of analysis include (1) identifying thematic aspects, (2) extracting thematic statements, (3) creating linguistic transformations, and (4) extracting thematic descriptions (Ritruechai et al., 2018). The transcripts of the interviews were read multiple times to gain a holistic comprehension of the information. All essential parts were marked up with codes. The initial coding was done by the first and second authors in Bahasa Indonesia, and then similar data were grouped into sub-themes and themes. The findings were translated into English by the first and second authors and then reviewed for accuracy by the third and fourth authors. Finally, the team discussed and agreed on the sub-themes and themes.

Trustworthiness

The researchers utilized specific rules to gain rigor and trustworthy criteria to ensure the study’s methodological soundness. Firstly, using a well-known method for phenomenological research (Van Manen, 1990) provided rigor. Additionally, evaluation methods of Guba and Lincoln (1989) were utilized, which included staying in touch with the participants for a long time and being honest about the study’s focus, in-depth data analysis, discussion of emerging themes with participants, and modification of themes based on participant input (Polit & Beck, 2017). These processes were documented in Excel files to ensure confirmability and dependability, which included participant descriptions in the final report to illustrate the applicability of the study’s findings. Furthermore, to ensure the credibility of the study, participants received a process summary and diagram, and member checks were conducted. In addition, qualitative research and nursing leadership experts were consulted throughout the study to improve accuracy. Finally, transferability was provided by explaining the study’s context, background, and stage in the introduction and choosing participants with the greatest possible variance.

Ethical Considerations

The Bali Institute of Technology and Health Research Ethics Committee (No. 04.0554/KEPITEKES-BALI/XI/2021) granted ethical approval for the study and data collection. Before participating, participants were provided with written and verbal information regarding the study’s purpose and methods. After agreeing to participate by signing the consent form and establishing a time and place for the interview, participants could withdraw at any point before data collection was concluded. Each interview was assigned a code instead of being identified by name or institution to ensure confidentiality and protect participants’ privacy. As a result, their identities and information were kept confidential.

Strategies in Resolving Ethical Dilemmas

Nurse team leaders have to use appropriate strategies when dealing with an ethical dilemma, especially when the problems involve patients. The techniques include seeking the facts, stepping back, considering support, and standing by patients.

Seeking the fact. Nurses have to seek facts to solve the problem. First, the patient’s complaint has to be checked and rechecked to confirm the problem. Then, they need to check all nursing staff and other teams. The participants express this:

“A caregiver complained about my member (nurse) that she (member) refused to answer and give information about everything when she injected the new chemical medicine to my son (caregiver’s son), and just said “don’t know” when I (caregiver) asked. At that time, I (Nurse) was head of the nursing team. So, I learned the truth from the caregiver, my member nurse, and other colleagues. It was found that the nurse was acting really badly.” (N 5)

Stepping back. The nurse team leaders should be aware of their position. If a problem might become bigger, it is better to step back. They also need to remind their staff to do the same. The participants state this:

“I (Nurse team leader) saw my member (Nurse) talk with a male family caregiver who was drunk. I walked and told my member to go back to the nurse station because the headward called to ask about her job.” (N 1)

“I have a lot of bad experiences. Now, I understand, I have to consider our position before dealing with the problem.” (N 3)

Considering support. Asking for another team’s support is crucial to give direction when deciding, particularly to follow up on patient treatment, because there are different situations among respondents. It is expressed by the participants:

“Actually, at the hospital, there are procedures and policies regarding presenting a palliative team, but this condition or presenting a palliative team cannot be brought to us immediately.” (N 4)

“There was a time I [team leader] was not so sure which way was correct, so my team and I decided to call the expert [Nurse who takes responsibility for the abortion policy of the province] to get support and information.” (N 13)

Standing by the patient. Hospitals need to gain benefits to maintain their employees and keep the facilities. However, the nurse’s position is sometimes a dilemma between the patient’s condition and the workplace need. The participants stated:

“An ethical situation arose when a patient had to discharge because they wanted to die at home. The breathing machine and oxygen tank were often not enough to lend because, if allowed, they borrowed to back home, and during that time, patients still survived. While in the hospital, there might have a case(s) with a greater need to use it. I [team leader] and the team have to decide what should be done to benefit all patients equally.” (N 2)

“When I [team leader] was taking care of underprivileged patients who used BPJS [Indonesia Universal Health Coverage], my manager said that the patient should be referred to another hospital because the complicated and long procedure for claiming will harm the hospital. I’m in a dilemma with this condition. Unfortunately, I need to follow the instruction, but manage to help the patient first.” (N 6)

Challenges in Addressing Ethical Issues

Seniority. Senior has a big responsibility as a model, and junior brings new hopes because they are updated with the latest knowledge. However, there are two different perspectives between seniors and juniors, in which juniors feel the senior pressures at work, while seniors think that juniors are too confident.

Juniors expressed this:

“I want to report this to our nurse manager, but I am afraid that my seniors will get angry and complain.” (N 12)

“I tried many times to remind teammate or other healthcare about following the standard, but many times I get trouble from the coordinator or above.” (N 8)

Seniors stated this:

“The senior nurses had the experience doing nursing so long and learned a lot about mistakes. I understand there are bad and good role models, but they can learn from us” (N 10)

“New generation is so confident. They do not care even though seniors try to remind them.” (N 5)

Trust issue. In dealing with ethical challenges, nurses must have excellent teamwork, which requires trust. However, in this study, the trust issue is the problem. The participants state this:

“I’m here as a primary nurse [nurse team leader], I have a bigger responsibility, so when I’m going to delegate an activity to a colleague, it’s a little difficult because my colleagues feel they can’t handle it.” (N 7)

“One time, when I was a staff nurse, after I injected the wrong medicine into patients, my team leader didn’t trust me to do injections when working with her. She will ask for checking many times, or she chose to do it herself even though she did not have the injecting assignment. That’s the lesson I learned when I become a team leader now” (N 5)

Lack of reflection and ethics training. The participants stated that the past mistakes made by the nurses should be discussed in pre or post-conferences during the shifts or in a forum to avoid repeating mistakes in the future. This also should be supported by the hospital to provide nurses with ethics training to raise awareness. Participants stated this:

“It will be beneficial for learning if the past mistakes can be discussed.” (N 6)

“We rarely take part in the training. The hospital said there is no financial support for that. We are encouraged to take the training independently.” (N 2)

“When there was a nurse who injected the wrong medicine, the head nurse instructed team leaders and staff nurses to observe her performance at all shifts. That nurse felt down, and she decided to resign. No reflection after that.” (N 1)

“When the hospital committees solve the problems related to nursing errors or ethical mistakes, they do not spread the solution. Many nurses say they do not know. So, how can we deal with this problem which has persisted for many years?” (N 3)

Implications for Nursing Practice and Hospital Policy

Ethical dilemmas cannot be stopped or avoided, and nurse team leaders have to approach them carefully. They need to consider the nurse’s position and reduce tension by remaining aware and calm. Unethical decisions can occur if they cannot adopt moral reasoning and understanding, leading to unclear nursing roles. The problem arises because of a conflict of interest between the patient and the workplace. Meanwhile, nurse team leaders should unite their team by training seniors as role models and encouraging knowledge-sharing and ethical experiences to establish a positive learning atmosphere. Additionally, the workplace environment is essential in motivating nurses to reflect and learn from ethical dilemma issues or study from mistakes. Finally, an interdisciplinary policy is necessary to avoid blaming individuals when facing ethical problems.

Strengths and Limitations

This study was the first in Indonesia to explore nurse team leaders’ experiences in dealing with ethical dilemmas, making it a valuable contribution. However, the findings could not be generalized, which require further research for confirmation.