Subservient interactions and bullying in the workplace
Subservient interactions between physicians (or even nursing managers) and nurses emerged as substantial barriers to nurses raising effective conscientious objection. This is not surprising because nursing personnel in Greece are not treated by physicians as professionals who are colleagues on shared work projects.
While nurse-physician collaborative relationships are traditionally characterized by subservient interactions, namely, nurse subservience and physician dominance, in the contemporary context of nursing schools, it is emphasized that physicians and nursing personnel should collaborate as colleagues [28]. This is in line with the fact that in many countries, there is university-level education in nursing. At any rate, the role that the existing health-system framework assigns to nurses is of great importance. It should be highlighted that the structure of the modern health care system has replaced the traditional individual physician-healer by a healing team consisting of various health providers. Nurses play a critical role in curative and preventive care. They are necessary to meet the goals of population health and patient satisfaction. The vast majority of health care services are mediated through nurses.
Importantly, until a few years ago in Greece, there was only one university school of nursing at the National and Kapodistrian University of Athens. Recently, many university nursing schools have started functioning in the country. At present, nurses working in the National Healthcare System rarely graduate from university nursing schools. This exaggerates the already existing problems related to subservient interactions between nurses and physicians.
Considering nursing personnel at the core of healthcare provision, researchers are compelled to further explore the conscientious objection of nursing personnel. When a nurse contributes to a medical procedure that goes against her core values and beliefs (namely, against her conscience), this may result in harm not only of their moral integrity but also of their health, since it may cause to herself negative outcomes such as burnout due to a high level of moral distress.
Importantly, the interactions between nurses and physicians should be coherent and used to conduct good communication in healthcare workplaces. Suboptimally or intimidating relationships between physicians and nursing personnel can bring about a situation that may have a devastating impact on patients. A healthy work environment that promotes patient safety requires good communication and collaboration between physicians and nurses [29, 30].
It has been suggested that nurses have more positive attitudes toward collaboration than physicians [28, 30]. In addition, nurses and physicians are reported to have differing opinions regarding what might constitute an operational definition of effective collaboration [28].
Suboptimal communication and support at work
In line with the findings of this study, the role of nurse leaders has been highlighted in the literature related to the topic of nurses’ conscientious objection. Ford et al. argue that ‘nurse leaders need to take action to create morally supportive environments for nurses...to engage in open dialogue and action regarding conflict of conscience’ ‘which are critical for the continuing moral development of nurses in Canada’ [31]. Therefore, according to the authors, ‘nurse leaders need to further develop the understanding of conflicts of conscience through education, well-written guidelines for conscientious objection in workplaces and engagement in research to uncover underlying barriers to the raising of conscientious objections...’. Lamb and Evans et al. found that ‘support from leadership, regulatory bodies, and policy for nurses' conscience rights are indicated to address nurses' conscience issues in practice settings’ [17]. In that connection, the Nursing and Midwifery Council, UK, state “Paragraph 4.4 of the Code states that nurses, midwives and nursing associates who have a conscientious objection must tell colleagues, their manager and the person receiving care that they have a conscientious objection to a particular procedure. They must arrange for a suitably qualified colleague to take over responsibility for that person’s care” [32].
Many participants in this study stressed the factors ‘communication with other health professionals or physicians in the workplace’ and ‘adequate support.’ This is not surprising, provided that contextualized relationships and trust are core elements of healthcare. This is emphasized by Milligan and Jones, who state that ‘dialogue and communication lie at the ethical core of human interactions in healthcare’ [29]. These elements are essential for improving the quality of healthcare services. It is the responsibility of each group of health workers to improve communication at workplaces, which can improve patient safety and quality of care in their healthcare institutions.
Furthermore, bullying in the workplace emerged as a substantial barrier to nurses expressing moral objections. Workplace gossip, criticism or even rejection threatens nurses’ psychological well-being and perhaps their careers [33]. This may occur in addition to the fact that sensitive nurses may experience compassion fatigue, empathetic distress, or moral distress due to themselves being constrained from openly expressing their moral concerns about medical procedures in which they have to participate.
Missing legal protection against job insecurity
The Greek legal framework relating to nurses’ conscientious objection has already been presented above. While conscientious objection has been included in Greek legislation, there is little guidance to help nurses express their conscientious objection. This is also the case for other countries. Czekajewska et al. very recently stated, ‘while the conscience clause is rarely invoked in Poland, most healthcare professionals declare that the current legal regulations in that sphere are unclear and inaccurate’ [22]. Dobrowolska et al. state, ‘Regulation in the United Kingdom is limited to reproductive health, while in Poland, there are no specific procedures to which nurses can apply an objection’ [20]. The guidance of the use of conscientious objection in nursing has a highly political dimension. Eagen-Torkko and Levi have every right to state, ‘Although guidance for the use of conscientious objection has developed in both nursing and midwifery, changes in the political landscape may be creating a source of conflict between providers and the use of conscientious objection’ [34].
‘Futile care’ gives rise to nurses’ conscientious objections
Most of the participants in this study raised ethical concerns related to so-called ‘futile care’. Clinical situations that involve futility care are extremely challenging from an ethical viewpoint and often give rise to health providers’ conscientious objection. Katz put it best in saying, ‘If treatments fail to release our patients from the preoccupation with the illness and do not allow them to pursue their life goals, then perhaps that treatment is futile’ [35]. Medical futility is ‘inherently a value-laden determination’ [36]. Furthermore, ‘a fully objective and concrete definition of futility is unattainable’ [36]. Indeed, Voultsos et al. state, ‘it is extremely difficult to precisely define medical futility, in part because it can depend on subjective aspects such as the values and preferences of individual patients as well as whether a proposed interventions can actually meet its intended goals’ [37]. The stakeholders involved in a clinical situation (i.e. patient, physicians, nurses, relatives/caregivers) may perceive the concept of medical futility differently. The judgment concerning whether a medical treatment is futile involves evaluative judgments. Moreover, the perceived definition of futile care may differ from nurse to nurse [37].
Nurses who feel impeded in expressing their conscientious objection to providing futile care or feel unable to provide palliative care adequately may feel disempowered and/or experience frustration, thus being led to experience moral distress (in the original/strict sense of the term) [38–41]. Moral distress (in the original/strict sense of the term) occurs when a nurse is constrained in some way from taking an action that she considers morally correct [42, 43]. More precisely, Prompahakul states, ‘The most commonly cited clinical causes of moral distress were providing futile care for end-of-life patients [44]. In a similar vein, Nikbakht et al. identified causes of nurses’ moral distress related to ‘respectful end of life care’ and ‘futile care’ [45].
Nurses experienced mild uncertainty about their ethical concerns
Rassin measured professional and personal values among nurses and found that ‘the top 10 rated values all concerned nurses' responsibility towards patients’ [46]. Moral integrity is a moral unity between personal and professional values and responsibilities [2].
Importantly, many of the participants in this study appeared to be deeply convicted about the correctness of their moral judgements. At any rate, it is crucial to bear in mind that according to psychology, people tend to be overconfident in their judgments [47]. However, while participants were detailing their previous experiences with ethically challenging situations involving futile care, reading between the lines (with the help of field notes), the researchers would say that participants had a strong sense of professional responsibility. This sense of responsibility caused participants to feel some amount of moral uncertainty. This last finding deserves further discussion. Morally challenging situations involve, to a greater or lesser extent, some kind of epistemic, social or normative uncertainty. Addressing (i.e. through education), challenging ethical issues (related to nurses’ moral concerns giving rise to conscientious objections) in the environment of nursing practice is complex [17]. Ethical nursing practice requires morally inclusive environments able to address challenging ethical questions raised by nurses [18]. Lamb, Babenko-Mould et al. state, ‘The need for education across nursing, healthcare disciplines and socio-political sectors is essential to respond to nurses' ethical concerns giving rise to objections’ [18]. Uncertainty about the patient’s medical condition operates as a barrier to making a proper and fair moral judgment about the refusal to provide further medical treatment. Relevant knowledge, training and experience are required for making ethical decisions.
A supportive ethical climate where nurses discuss and share their experiences with other health providers as moral peers is required to address their ethical concerns in clinical practice. Persut et al. argue that nurses’ conscientious objection should not be arbitrary, based on ‘prejudice, fear on convenience’, but on their deeply reflective choice. Nurses should be instructed to conscientiously object to providing care or participating in care after having reflected upon their moral responsibility. Their objection should not be based on what their patient wills (The Nursing and Midwifery Council, UK, The Code, § 20.7., 2015, updated: 2018) [32]. Nurses who are conscientious objectors should reflect carefully, critically and in a detailed way about their intuitions [48]. A supportive ethical climate is essential for nurses to be able to reflect upon their moral responsibility. Panchuk and Thirsk state that conscientious objection may not be a viable option in rural and remote settings in Canada due to the limitations that may exist in these settings, such as external support or staffing constraints [49]. In addition, nurses’ refusal based on self-interest should not be considered a conscientious objection [50, p. 20].
Constraint distress
Nurses’ claims are less recognized than those of physicians, which have long been accepted [51]. It is argued that nurses cannot object to giving patients indirect aid, such as patient preparation and aftercare, serving meals to patients who underwent a morally rejected (from the perspective of nurses) medical treatment or typing referral letters [52]. Furthermore, it is argued that nurses’ decision to raise a conscientious objection to the provision of a particular service means that other health professionals may be required to assume an additional workload that they may resent [9]. Fovargue and Neal state that ‘lack of clarity about the proper limits of conscientious refusal to participate in particular healthcare practices has given rise to fears that, in the absence of clear parameters, conscience-based exemptions may become increasingly widespread, leading to intolerable burdens on health professionals, patients, and institutions’ [53]. Furthermore, given that determining the limits of conscientious objection is complex and vague, nurses’ conscientious objection can easily act as structural violence by infringing on the exercise of patients’ rights to health care services. Nonetheless, ‘there is consensus that the right to objection among nurses is an important, acknowledged part of nursing practice’ [20]. However, nurses’ conscientious objection has not yet received the recognition it deserves. Lamb and Pesut have every right to argue that emphasizing the relational nature of nursing may cause nurses to become aware of themselves as conscientious professionals [54].
At any rate, nurses who are not allowed to raise their ethical concerns and make conscientious objections may develop moral distress. Compromising nurses’ moral integrity and reducing their autonomy may lead to moral distress [55]. Nurses’ moral distress was initially conceptualized in the strict (and most influential) sense of the term, according to the original definition coined by Jameton [43]. Nurses experience moral distress when they feel ‘disempowered or impeded’ in taking the course of action they consider to be ethically right [38]. Mills and Cortezzo state that moral distress has historically been described as a feeling ‘resulting from poor communication, discrepant values, and paternalistic hierarchy’ [56]. However, as the definition of moral distress has later been broadened, it may include not only situations involving nurses feeling constrained (constraint distress) but also situations involving nurses feeling moral uncertainty (uncertainty distress) [42]. Uncertainty distress may vary between groups of health professionals [42]. While participants in this study appeared to have experienced constraint distress, few of them appeared to have experienced (mild) moral uncertainty. As nurses are not the ultimate decider and given the subservient relationship between nurses and physicians, it is most likely that nurses suffer from constraint distress rather than uncertainty distress.
The intensive care unit is an ethically challenging environment in which nurses are most likely to have strong ethical concerns and make conscientious objections. This deserves much attention. Chiafery et al. state that ‘nursing ethics huddles to decrease moral distress among nurses in the intensive care unit’ [57].
Factors shaping participants’ core values
The quality of the education they had received, the way they grew up in their family and religion emerged as substantial factors that contributed towards shaping nurses’ values on which a conscientious objection might be grounded.
Not surprisingly, religious beliefs are pointed out in the literature as factors affecting nurses’ conscience-based unwillingness to participate in care in not only Christian but also Muslim countries [21, 58–60]. Brown et al. state, ‘Nonparticipation was influenced by their (a) previous personal and professional experiences, (b) comfort with death, (c) conceptualization of duty, (d) preferred end-of-life care approaches, (e) faith or spirituality beliefs, (f) self-accountability, (g) consideration of emotional labor, and (h) future emotional impact’ [59]. Velasco Sanz et al. state, ‘Different authors point out that nurses' perceptions and attitudes towards Euthanasia are conditioned by different factors, such as religion, gender, poor palliative care, legality and the patient's right to die’ [60].
Nurses considered their remote contribution as participation that can give rise to conscientious objection
Without determining the degree of participation giving rise to conscientious objection, nurses’ conscientious objection can easily act as structural violence by infringing on the exercise of patients’ rights to health care services. It emerges from a literature review that many scholars have concerns about the proper limits of conscientious refusal to participate in particular healthcare activities [61]. Determining these limits is complex and vague. Many theorists have put great deal of effort into getting the line of distinction between blameworthy and innocent participation in a particular healthcare activity as sharp as possible [61]. While the participants in this study complained of a lack of legal security pertaining to their professional rights and job stability, they avoided making any reference to the degree of proximity to an activity (regarded as morally wrongful), which might give rise to conscientious objection. However, they considered their remote contribution as participation that can give rise to conscientious objection. The degree of remoteness or proximity seems to be determined by the participants themselves.