Expert Nurses’ Coping Experiences in Ethically Challenging Situations: a Qualitative Study

Nurses encounter ethically challenging situations in everyday practice. This study aimed to explore expert nurses’ experiences of coping with ethically challenging situations to understand nurses’ ethical competence. Methods

The ndings of this study showed that coping strategies of expert nurses are mostly consistent with the attributes of previously de ned ethical competence in healthcare, and the way for expert nurses to deal with ethically challenging situations is to care for patients faithfully according to the spirit of caring. It is ethical to be faithful to the nature of caring. System-wide early counselling and interventions should be

Background
Ethically challenging situations that nurses encounter in everyday practice are usually situations in which they know the right thing but do not do it [1]. Sometimes, nurses have di culty in even recognising the right course of action [2]. Thus far, it has been tricky to develop a clear de nition of an ethically challenging situation of nursing. However, some studies on registered nurses' experience of ethical issues in their practice suggest what ethically challenging situations are in nursing practice. For example, nurses in the emergency department reported their ethically challenging situations as that being close to the suffering or death of people, being unsure about how to express their feelings, having a heavy responsibility, and working in an open space where many people are looking [3]. Nurses providing childhood cancer care in Sweden were often concerned about infringing on patients' autonomy, deciding on the appropriate treatment level, and dealing with con icting perspectives within health professional teams [4].
In ethically challenging situations, what nurses require is the ethical competence to cope with such situations. Ethical competence can be de ned in terms of individuals' character strength (good character traits), ethical awareness (ethical perception), moral judgment skills, and willingness to do the right thing [5]. Ethical competence depends on the ability to detect ethically challenging situations, consider various courses of action, and implement them [1]. Ethical competence results in positive outcomes for the patient and reduces nurses' moral distress [5], and the authors believe that exploring how nurses cope with ethically challenging situations could be one of the ways to understand nurses' ethical competence.
Numerous studies worldwide have examined ethically challenging situations among nurses in clinical settings. Rathert et al. [6] found that more than half of the surveyed 290 nursing staff in acute care hospitals in the United States experienced ethical dilemmas and con icts frequently (i.e. several times a month to daily). Healthcare professionals (including nurses) in Sweden described ethically di cult situations as a sense of powerlessness in managing the complex emotional needs of patients and relatives, providing unequal care, and uncertainty over who the primary care decision-maker is [7]. A study in South Korea found that con icts between nurses and physicians (or other nurses) were the most frequently encountered ethically challenging situations across hospital departments [8]. Because ethically challenging situations can lead to moral distress in nurses [6,9,10], which can directly harm patients along with nurses' own personal and professional lives [11], it is crucial for nurses to cope with ethically challenging situations well.
In reviewing the literature, the authors found a few studies on nurses' coping strategies to deal with ethically challenging situations. The previous studies [9,10,12,13] reported some ways of coping. For example, nurses in a hemodialysis centre tried to cultivate dialogue with physicians about ethical concerns but largely failed in doing so, causing them to continually feel uncertain and act against their conscience [12]. Oncology nurses mainly remained silent about ethical concerns, which shaped a culture of avoidance in conversations on the prognosis and end-of-life treatment with patients, families, and physicians [13]. Lievrouw et al. [9] discerned four dominant strategies of health professionals in oncology: thoroughness (weighing up thoroughly and always doubting), autonomy, compromise, and intuition. As a result of a literature review of coping resources [10], nurses use different coping resources, which can be positive when they lead to dialogue and re ection, or negative, when they cause the professional to accept and conform to the context, experiencing di cult ethical situations alone, without the support of colleagues or the institution, and being prone to a feeling of moral distress.
These previous studies do contribute to our understanding of nurses' dealing with ethically challenging situations. Still, they did not fully explore how nurses deal with ethically challenging situations in nursing practice. Most importantly, the authors were interested in expert nurses' ways of coping because they have abundant experience in dealing with ethically challenging situations.

Aim
This study aimed to explore expert nurses' experience of coping in ethically challenging situations in South Korea.

Design
This study used a descriptive phenomenological research method, suggested by Giorgi [14], which is suited for describing an experience from the perspective of the person experiencing it.

Participants
To recruit expert nurses in clinical settings through purposive sampling, the authors selected a general hospital located in the capital city of South Korea because the hospital has a systematic career evaluation system for nurses. The career evaluation system of this general hospital assesses and develops the careers of nurses according to four stages: 1) the rst stage, a nurse complies with nursing standards and performs nursing tasks without di culty, 2) the second stage, a nurse adjusts nursing goals and priorities, and plays the role of a preceptor, 3) the third stage, a nurse is an expert who can individualise and manage nursing needs of different nursing situations, and 4) the fourth stage, a nurse is a head nurse or a professional clinical nurse who is capable of being a role model for nurses [15].
Nursing team managers or unit managers were asked to recommend expert nurses whose expertise was determined using the career evaluation system in each nursing unit. Recommended expert nurses were invited to this study; nally, 26 registered nurses participated voluntarily. All these participants were women, and their average age was 36.7 years (range: 32-44 years). They had been employed in the current hospital for an average of 12 years and one month (range: 9 years and nine months to 17 years and ten months; Table 1).

Data collection
All data were collected through six small group interviews twice. Each group consisted of four to ve participants, and the participants in each group remained unchanged until the end of the data collection. The authors chose the small group interview because it helps to 'create a natural communicative context for telling stories from practice, allowing peers to talk to one another as they ordinarily talk' in a phenomenological study [16, p.109]. The participants of this study did not con ict with or contradicted each other but empathised with each other.
The face-to-face interviews were conducted by the authors (K and O). The authors informed each nurse of the main interview question (e.g. 'How did you cope with ethically challenging situations you experienced while working as a nurse?') via e-mail or phone one week before the interview. The interview location was a hospital counselling room or a café near the hospital.
At the beginning of the rst interview, participants completed a questionnaire asking about their general characteristics, such as their age, sex, job title, educational background, and work experience. The interview began with the question: 'How did you deal with ethically challenging situations while working?' Then, the authors asked open-ended questions such as, 'Please tell me what you experienced while dealing with ethically challenging situations.' The interviews were conducted in Korean, and the data analysis and description of results were in Korean.
Then, one of the authors wrote the manuscript in English, and an English professional editor edited this paper. Each interview was recorded with the consent of the participants and lasted for 2-2.5 hours. One to two weeks after the rst interview, the authors asked participants for additional interviews because some contents of the transcripts needed further clari cation. Interviews were continued until data saturation.

Ethical considerations
The Institutional Review Board of the hospital bioethics committee approved this study. Participants were informed of the study purpose and methods and their right to withdraw participation at any time up until the study was completed. The participants voluntarily signed an informed consent form. Their privacy and con dentiality were ensured by referring to them using alphabets rather than their names.

Data analysis
A phenomenological approach [14] was used to interpret the content of the text data through systematic coding and identi cation of themes. The audio-recorded interview data were transcribed verbatim by the authors (K and O). Giorgi [14] recommended a three-tiered analysis. First, all authors read the interview transcripts repeatedly to grasp the overall meaning of the text. In the second step, meaningful statements are selected; so, two authors (K and O) underlined the sentences or phrases considered most relevant to the coping with ethically di cult situations. Third, each meaning unit (i.e. the participants' own words) was transformed into 'phenomenologically psychologically sensitive expressions' as described by Giorgi [14]. More speci cally, two authors (K and O) summarised the meaning of each sentence using thirdperson expressions, making a coding list. All authors met several times to review the list of codings and discuss how to group them into more abstract themes. Codings were sorted and categorised into subthemes based on the similarity of meaning, which was then grouped into themes. For example, awareness of human dignity, self-re ection, and ethical questioning while working were conceptualised into a theme of 'self-monitoring of ethical insensitivity'. We then grouped the sub-themes into main themes-self-monitoring of ethical insensitivity, maintaining honesty, and actively correcting mistakesinto an essential theme, 'being faithful to the nature of caring'.

Rigour
The study's rigour was examined in terms of credibility, dependability, and transferability, as described by Graneheim and Lundman [17]. For the credibility, the authors (one of whom was an expert in qualitative research) discussed the text several times until we all agreed with the way the data were labelled and sorted. Also, the authors showed the results of the analysis to several participants who were able to take time and made sure that the results of the study match what the participants experienced. Regarding dependability, discussion among authors continued to select consistent themes during data analysis. Finally, to ensure transferability, the authors tried to describe the general characteristics of participants and ethical situations in detail for the reader to understand.

Results
The essential theme of expert nurses' experiences of coping with ethically challenging situations was 'being faithful to the nature of caring'. This essential theme, in turn, comprised three themes: selfmonitoring of ethical insensitivity, maintaining honesty, and actively acting as an advocate.
Theme 1: Self-monitoring of ethical insensitivity The expert nurses in this study were continually monitoring their ethical insensitivity consciously when confronted with ethically challenging situations. Self-monitoring of ethical insensitivity was a cyclical process formed from three sub-themes: awareness of human dignity, self-re ecting, and ethical questioning.
Sub-theme 1: Awareness of human dignity Participants were constantly aware of the human dignity of their patients in the face of ethically challenging situations. This awareness gave participants new insights into their role as a nurse, bringing them a sense of duty in caring for humans.
'A patient (waiting for organ transplants) was whispering, "If I live, someone is dead, right?"... I was busy, and I had not even thought about it. Yes. ... The work of saving someone (through organ transplants) requires someone to have died. It is not a situation that I can ignore using my busyness as an excuse' (Participant A, 11 years of experience, medical department).
When expert nurses began realising that they were caring for a human, they became worried whether they would undermine human dignity. In busy and often complicated clinical situations, nurses frequently used patients' medical diagnosis and room number (e.g. 'pneumonia, 1203') instead of patients' names when talking to other nurses and medical staff, which some believed would help to limit their mistakes in nursing practice; however, they also acknowledged that nurses sometimes were not treating patients with dignity.
Sub-theme 2: Self-re ecting Participants often remembered and self-re ected on moments where they encountered ethically challenging situations such as when the workload limited their opportunities to express compassion to patients. Moreover, some participants re ected how nurses lose opportunities to hold a patient's hand or speak warmly to patients and their relatives, feeling that they had not done their job as nurses in those instances. Some participants re ected situations where nurses could not talk about the patient's treatment or prognosis (often at the doctor's orders). Then they experienced agony in having to observe helplessly from the periphery, mainly when the life-saving treatment was hopeless. 'It's clear that this patient will not be able to live beyond a few days, but the doctor continues the treatment until the end, and family members want to let the patient go comfortably. I think it is not in the best interest of the patient or his family if he is made to keep breathing, take high doses of drugs, undergo dialysis, and use a ventilator' (Participant Q, 14 years of experience, surgical department).

Sub-theme 3: Ethical questioning
Participants asked themselves who their nursing action was for and whether they were doing right in nursing practice. Ethical questioning arose in situations where participants had to keep a secret about a cancer diagnosis, apply physical restraints to patients, and provide care for patients with DNRs. Such as, some participants were questioning whether it was right not to tell patients with cancer the truth of their diagnosis as requested by the family caregivers or to change the position every two hours to prevent bedsores to patients who are about to die. 'It's an aging society, and there are a lot of older people who do not want their families to know about it (their cancer diagnosis). Most of us ensure con dentiality, but is it right to keep it a secret because the patient is so old? Family members may give up treatment because patients are old. Caregivers don't let patients decide for themselves about treatment, is this right?' (Participant M, 17 years and 10 months of experience, surgical department) Theme 2: Maintaining honesty All participants in this study thought that adhering to standards of nursing was fundamental to honesty. They strove to be honest by adhering to principles and standards of nursing and internalising honesty.
Sub-theme 1: Adhering to principles and standards of nursing practice Participants realised that adhering to the nursing standards and principles was the basis of ethical nursing practice. Many participants considered it unethical for a nurse to not know the principles and standards of nursing practice. They reported that even simple nursing tasks had to be performed faithfully and transparently in accordance with these standards. Examples of these standards were giving medications only as prescribed, not fabricating nursing records, and not acting hypocritically to cover up a problem. 'In the past, a patient who was waiting for an organ transplant sometimes asked me to record his condition as worse than it was. He asked me to record that he's unconscious… I told the patient that it wasn't possible' (Participant P, 11 years and three months of experience, surgical department).
Moreover, participants rejected doctors' unscrupulous orders and did not tolerate other colleagues' mistakes. Nurses sometimes encountered con icts in their relationships with other nurses, doctors, patients, and relatives of patients while adhering to these principles.

Sub-theme 2: Internalising honesty
All the participants mentioned that honesty is a virtue for nurses in any ethically challenging situations. Many situations would go unnoticed by others, even if nurses are not honest about them. High workloads or situations in which others' actions are di cult to observe often presented participants with the opportunity to make questionable choices for convenience rather than be honest. Still, participants mentioned that they continually strove to internalise a sense of honesty to avoid giving in to unethical temptations.
'The most important thing is honesty. I had to get ready for surgery really quickly, but then my collar or something touched my hand. I was afraid I'd get in trouble if I told my senior. However, it's wrong to pretend that nothing happened. That's why I always say I should not pretend that I do not know. I also tell other nurses not to do that'. (Participant X, 12 years and three months of experience, Operation room) Theme 3: Actively acting as an advocate Sub-theme 1: Expressing oneself regarding the treatment or erroneous situation Participants actively participated in rounds with doctors and expressed their opinions on the treatment being given. Expert nurses accurately conveyed their opinions with con dence in conversations with doctors. For example, some participants asked the physician whether they had made a DNR decision too early. They also actively sought out physicians to solve problems (e.g. prescription errors). 'Even with dyspnea, I said to the doctor, "The current situation is not just an observation. The patient is showing Cheyne-Stokes breathing. You should come right away"' (Participant D, seven years and 10 months of experience, medical department).
When nurses and doctors had trouble communicating, participants would intercede to avoid any harm coming to the patient and various other ethical and legal problems (e.g. negligence of duty). Moreover, if fellow nurses or doctors did something wrong, participants mentioned this to the medical staff involved and asked to rectify the mistakes. When participants became team leaders, preceptors, and charge nurses, they began to more actively check for unethical behaviour, telling superiors and clinical professors, as well as other nurses, in advance about actions that might harm patient safety to prevent problems from occurring.
'When educating family members to wear gowns ... Now I have a voice, and I have been working as a responsible nurse since last year. I am trying to do as much as I can'. (Participant L, 11 years and six months of experience, surgical department) In situations where problem-solving was not possible at the personal level, participants acted at the organisational level. They reported the problem to the head nurse (i.e. the unit manager), and then collected and analysed data on recurring problematic situations and reported the results to the department of nursing administration.
Sub-theme 2: Being a mediator Participants helped in accurately conveying the opinions of the patient and family members to the physician during rounds, which helps maintain patients' self-determination in therapy. One participant even asked another participant to suspend a DNR order until it had been su ciently explained to patients and their family members.
The participants served as advisors to patients and family members to help them make the right choices. For example, a patient, who wanted to keep her illness a secret, raised an ethical issue about how her mother knew of her medical condition. After listening to the patient, the participant recognised that the patient was suffering because of a broken relationship with her mother, and thus actively mediated the problem as a patient advocate. Another participant reported how a patient had been prescribed a medicine that was convenient for medical staff but nancially burdensome to the patient, so she asked the doctor to correct the prescription by pointing out the patient's situation.
'The only persons who can stand up for patients are nurses. We are their spokesmen. When I looked up the child's past and current medical history, the child's father was unemployed. I then found that the price of medicine, even though it was insured, was 47,000 won ($46). ... I asked the doctor to prescribe the exact dose that was necessary' (Participant V, 13 years and ve months of experience, intensive care unit).

Discussion
This study explored expert nurses' experience of coping with ethically challenging situations to understand nurses' ethical competence in nursing practice. The ndings of this study are mostly consistent with the attributes of previously de ned ethical competence in healthcare [5,18,19]. Eriksson et al. [18] argued that ethical competence in healthcare must consist of being (virtues), doing (rules and principles), and knowing (critical re ection). The ndings of this study showed the contents of doing and knowing in greater detail than Eriksson et al. [18]. The expert nurses of this study expressed their 'knowing' as they were self-monitoring for ethical insensitivity through self-re ection and ethical questioning with an awareness of human dignity. Gallagher [19] de ned ethical competence as the possession of ethical knowledge, ethical perception, ethical re ection, and ethical behaviour. In this study, ethical knowledge was involved in the whole process of recognising, re ecting upon, and acting on ethical issues rather than expressed independently. For example, for a nurse to adhere to the standards of nursing, he/she must rst know the nursing standards.
All participants of this study also expressed ethical perception as an awareness of human dignity in ethically challenging situations. Gastmans [20, p. 146] proposed that the essence of nursing care is 'to provide care in response to the vulnerability of a human being in order to maintain, protect, and promote his or her dignity as much as possible'. Nurses have an ethical obligation to maintain and respect individuals' dignity and integrity [21]. All participants had realised the importance of preserving patients' dignity, which in turn made them continually re ect on what the correct course of action was in ethically challenging situations.
Ethical re ection is an essential attribute of ethical competence [18,19]. Using self-re ection and ethical questioning, all participants in this study habitually monitored their actions and thoughts to avoid ethical insensitivity while working in clinical settings. Ethical insensitivity or numbness is considered to be a loss of moral sensitivity [22], and believed to be one of the main ethical issues that nurses face [23]. Nurses may become ethically insensitive when they are too busy with work in clinical settings [21,23]. However, the participants in this study engaged in constant self-re ection to avoid ethical insensitivity. Selfawareness has been found to lead to greater competence in nursing [24]. Moreover, self-re ective behaviour (e.g. asking oneself 'What should I do?') was also helpful in making nurses' decision-making more ethical [25]. Nurses should engage in self-re ective behaviour to be more ethically competent, and self-re ection could be encouraged through conversation [18] with colleagues or re exive writing [25].
The expert nurses in this study mentioned the following types of ethical behaviours: adhering to principles and standards of nursing, internalising honesty, giving one's opinion on the treatment or erroneous situation, and being a mediator. Nurses have a responsibility to advocate for patients and their relatives, and are in an excellent position to be aware of the risk factors of ethical problems that may harm patients in clinical settings [26]. The participants could correct mistakes and resolve ethical con icts by actively expressing their views on patients' care and treatments by adhering to their own moral beliefs. Most of all, nurses must be given opportunities to voice their opinions in ethically challenging situations to advocate for patients' rights to health [27], and they require resources for dealing with their ethical quandaries [4]. Therefore, the system-level support aimed at enhancing the moral resilience of nurses is necessary [28] for an ethical work environment [29].

Limitations
Qualitative research is never intended to allow for generalisation, but it is necessary to obtain a su cient number of participants to describe a phenomenon comprehensively. In this respect, a limitation of this study is that expert nurses working in one general hospital in South Korea, rather than several hospitals, were included in the study. Another limitation concerns the selection criteria for expert nurses-we relied on the hospital's evaluation system, which is not nationally standardised; in the future, the criteria for de ning an expert nurse need to be universally standardised. Also, this study did not explore the role of the characteristic traits of expert nurses in coping with ethically challenging situations. Therefore, future research needs to study coping strategies, considering the moral character of nurses.

Conclusions
The results of this study suggest that the best way for expert nurses to deal with ethically challenging situations is to care for patients faithfully according to the spirit of caring. After all, the bene cial ways to cope with ethical issues require nurses to realise the need to preserve the dignity of the patient, engage in self-re ection and ethical questioning, and maintain honesty as much as possible by adhering to the nursing principles and standards and speaking out as patient advocates. This study could be helpful for nurses to cope with the ethical di culties they experience. Also, expert nurses' experience of dealing with ethically challenging situations could help in guiding new nurses and nursing students. Furthermore, system-wide early counselling and interventions should be established for nurses who have experienced ethical di culties to ensure ethical nursing practices. Nursing administrators should investigate ethically challenging situations and implement measures based on situations.

Declarations
Ethics approval and consent to participate This study was approved by the ethics committee of Asan Medical Center (2015-0035).

Consent for publication
Not applicable

Availability of data and materials
The datasets generated and/or analysed during the current study are not publicly available due to the small sample size, but anonymized data are available from the corresponding author on reasonable request.
Competing Interests