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Journal ArticleDOI

A Cross-Cultural Comparison of Nurses' Ethical Concerns

01 Nov 2008-Nursing Ethics (SAGE Publications)-Vol. 15, Iss: 6, pp 745-760
TL;DR: Comparing Swedish and Chinese nurses' experiences of ethical dilemmas and workplace distress in order to deepen understanding of the challenges neuroscience nurses encounter in different cultures indicates the importance of providing nurses with the tools to influence their own work situation and thereby reducing their work-related stress.
Abstract: The aim of this study was to compare Swedish and Chinese nurses' experiences of ethical dilemmas and workplace distress in order to deepen understanding of the challenges neuroscience nurses encounter in different cultures. Qualitative interviews from two previously performed empirical studies in Sweden and China were the basis of this comparative study. Four common content areas were identified in both studies: ethical dilemmas, workplace distress, quality of nursing and managing distress. The themes formulated within each content area were compared and synthesized into novel constellations by means of aggregated concept analysis. Despite wide differences in the two health care systems, the nurse participants had similar experiences with regard to work stress and a demanding work situation. They were struggling with similar ethical dilemmas, which concerned seriously ill patients and the possibilities of providing good care. This indicates the importance of providing nurses with the tools to influence their own work situation and thereby reducing their work-related stress.

Summary (2 min read)

Introduction

  • Health and medical services in Sweden are organized as a uniform, nationwide programme that gives each person the right of access to care based on personal medical needs.
  • 1,2 However, during approximately the last 20 years the Swedish health care system has undergone fundamental change.
  • Likewise, the health care system in China has undergone radical change since the 1980s owing to a move towards a market economy, leading to significant economic restructuring.
  • Ownership of health care facilities has been decentralized4 and private practices have become more common.
  • Thus their aim was to compare Swedish and Chinese nurses’ experiences of ethical dilemmas and workplace distress to deepen their understanding of the common and unique challenges nurses encounter in different cultures, focusing on the demanding field of neuroscience nursing.

Method

  • The analytical approach used was a form of aggregated concept analysis,18 in which researchers collect and use findings from other studies.
  • This analysis was performed to attain greater understanding and transferability of the nursing experiences investigated in the present study.
  • The two empirical studies in this comparative analysis12,13 used the same research design.
  • Schutz’s19 distinction between first- and second-order constructs was applied.
  • First-order constructs were represented by the nurses’ experiences during their daily work in each country as described in the previous studies.

Participants

  • The physicians in charge and the head nurses at the two hospitals concerned gave permission for performance of the two previous studies12,13 after being informed of their purpose.
  • Nurse participation was based on informed consent.
  • The data collection in China was restricted to a period of two days and all nurses working day shifts at Vaxjo Universitet on February 11, 2010 http://nej.sagepub.comDownloaded from during that time were approached.
  • Data collection and analysis of first-order constructs.
  • The interviews were carried out in both countries by two of the Swedish researchers (GA and BW) using a conversational format.

Years worked in nursing

  • At Vaxjo Universitet on February 11, 2010 http://nej.sagepub.comDownloaded from guides were the same in both countries with the exception of the language used (Swedish and English, respectively) and consisted of the following questions:.
  • Thereafter, the themes identified within each content area of the empirical studies were compared.
  • When the nurses voiced a different opinion the physicians did not acknowledge the nurses’ professional competence and knowledge about patients’ situation, putting them in the difficult position of having to carry out orders they did not consider appropriate and useful.
  • In China the nurses’ experiences were very similar, the main complaint being a lack of respect for them as professionals on the part of physicians, which created frustration and discontent.

Discussion

  • The aim of the present study was to compare Swedish and Chinese nurses’ experiences of workplace distress and ethical dilemmas in a neurological setting to deepen their understanding of the challenges neuroscience nurses encounter in different cultures.
  • In spite of wide differences in the two health care systems,1,2,4 both the Swedish and Chinese nurses had very similar experiences.
  • Caring for seriously ill patients, especially young adults, was a factor that strongly affected the nurses’ working situation in both countries and resulted in emotional strain.
  • 28 MacDonald27 highlights in her review the ethical problems experienced by nurses that are related to institutional or health policy constraints.
  • It is difficult to know whether this difference in nursing behaviour depends on cultural or educational differences, but the nursing profession is not widely respected and acknowledged in China.

Conclusion

  • The results show that neuroscience nurses have demanding jobs in both Sweden and China.
  • The nurses in both these countries were struggling with largely similar ethical dilemmas, even though the causes of the dilemmas could differ.
  • The nurses also had similar experiences of workplace distress, saying that they were not professionally respected.
  • The ways in which they handled stress at work were different, but both groups of nurses used similar strategies to relax after work.
  • Thus, this study indicates that the ethical conflicts described by nurses in various countries are global in nature.

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Nursing Ethics
DOI: 10.1177/0969733008095385
2008; 15; 745 Nurs Ethics
Barbro Wadensten, Stig Wenneberg, Marit Silén, Ping Fen Tang and Gerd Ahlström
A Cross-Cultural Comparison of Nurses' Ethical Concerns
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Nursing Ethics 2008 15 ( 6) © 2008 SAGE Publications 10.1177/0969733008095385
ACROSS-CULTURAL COMPARISON
OF
NURSES’E
THICAL CONCERNS
Barbro Wadensten, Stig Wenneberg, Marit Silén,
Ping Fen Tang and Gerd Ahlström
Key words: cross-cultural comparison; ethical dilemmas; nursing ethics; quality of
nursing; workplace distress
The aim of this study was to compare Swedish and Chinese nurses’ experiences of
ethical dilemmas and workplace distress in order to deepen understanding of the
challenges neuroscience nurses encounter in different cultures. Qualitative interviews
from two previously performed empirical studies in Sweden and China were the basis
of this comparative study. Four common content areas were identified in both studies:
ethical dilemmas, workplace distress, quality of nursing and managing distress. The
themes formulated within each content area were compared and synthesized into novel
constellations by means of aggregated concept analysis. Despite wide differences in the
two health care systems, the nurse participants had similar experiences with regard to
work stress and a demanding work situation. They were struggling with similar ethi-
cal dilemmas, which concerned seriously ill patients and the possibilities of providing
good care. This indicates the importance of providing nurses with the tools to influ-
ence their own work situation and thereby reducing their work-related stress.
Introduction
Health and medical services in Sweden are organized as a uniform, nationwide pro-
gramme that gives each person the right of access to care based on personal med-
ical needs.
1
The health care system is publicly financed and services are to a high
degree publicly provided.
1,2
However, during approximately the last 20 years the
Swedish health care system has undergone fundamental change. Its structure has
become more orientated towards provider–purchaser models. In addition, several
major organizational health care reforms were carried out during the 1990s, result-
ing in bed reductions in geriatric and psychiatric care.
2
Likewise, the health care sys-
tem in China has undergone radical change since the 1980s owing to a move towards
a market economy, leading to significant economic restructuring.
3
Ownership of
health care facilities has been decentralized
4
and private practices have become more
common.
5
General access to health care has been restricted during this process and
Address for correspondence: Gerd Ahlström, School of Health Sciences, Jönköping University,
SE-551 11 Jönköping, Sweden. Tel: 46 36 101196; Fax: 46 36 101180; E-mail:
gerd.ahlstrom@hhj.hj.se
at Vaxjo Universitet on February 11, 2010 http://nej.sagepub.comDownloaded from

746 B Wadensten et al.
Nursing Ethics 2008 15 (6)
the majority of the Chinese people do not have medical insurance coverage.
Simultaneously, there has been a transition in the types of illness occurring in China,
and the leading cause of death is now chronic disease.
4
These rapid changes may directly or indirectly influence nurses’ working situations
in China and Sweden. Increased workplace distress due to a shortage of nursing staff
has been described in previous Swedish studies.
6,7
This scarcity of resources has been
the basis for the growth of ethical problems.
8
Decision making with regard to life-
sustaining treatment is another area that gives rise to ethical dilemmas in Sweden.
9
By way of comparison, the major sources of stress for Chinese nurses are work over-
load and inadequate staffing, interpersonal relations, and dealing with hospital
administration.
10
The current modernization of Chinese society has also been noted
to contribute to increased workplace distress in the health care market.
11
Pang vividly
describes the resulting ethical dilemmas that nurses encounter daily in China.
4
Our research group has conducted three separate studies
12–14
on workplace stress
and the ethical problems that nurses encounter in Sweden and China. Exploring
nursing phenomena among populations with great cultural differences may help to
identify and further explore general patterns occurring across cultures. However,
only a few cross-cultural comparisons have been performed on nurse-related ethical
issues and they have mainly focused on nurses’ ethical reasoning
15,16
or ethical role
responsibilities.
17
We have not identified any cross-cultural study that explores the
differences in the ethical dilemmas that nurses may encounter in daily practice. Thus
our aim was to compare Swedish and Chinese nurses’ experiences of ethical dilem-
mas and workplace distress to deepen our understanding of the common and unique
challenges nurses encounter in different cultures, focusing on the demanding field
of neuroscience nursing.
Method
The analytical approach used was a form of aggregated concept analysis,
18
in which
researchers collect and use findings from other studies. This analysis was performed
to attain greater understanding and transferability of the nursing experiences inves-
tigated in the present study. The two empirical studies in this comparative analy-
sis
12,13
used the same research design. They involved recruitment of similar nursing
populations in China and Sweden and the same procedures for interviewing and
analysing the qualitative data obtained. Schutz’s
19
distinction between first- and
second-order constructs was applied. First-order constructs were represented by the
nurses’ experiences during their daily work in each country as described in the pre-
vious studies.
12,13
Second-order constructs were realized in the present study through
comparison and synthesis of these empirical results, leading to a higher level of
abstraction of the nursing phenomena under study.
Participants
The physicians in charge and the head nurses at the two hospitals concerned gave
permission for performance of the two previous studies
12,13
after being informed of
their purpose. Nurse participation was based on informed consent. The data collec-
tion in China was restricted to a period of two days and all nurses working day shifts
at Vaxjo Universitet on February 11, 2010 http://nej.sagepub.comDownloaded from

during that time were approached. Twenty of 22 eligible nurses agreed to participate.
Likewise in Sweden, all 20 nurses working day shifts in two neurological departments
were asked to take part, all but one of whom agreed. Thus a total of 41 nurses made
up the final research population, 20 being drawn from two neurological wards at a
hospital in China and 21 from two equivalent wards at a university hospital in
Sweden. In the written and oral information distributed preceding data collection, it
was clearly stated that participation was voluntary and that confidentiality was
assured. More details about the sampling procedure are described in the previous
studies.
12,13
Table 1 presents background characteristics of the participating nurses.
Data collection and analysis of first-order constructs
The interviews were carried out in both countries by two of the Swedish researchers
(GA and BW) using a conversational format. In China, two Chinese nurses (HZ and
LT) were interpreters and the interviews were conducted in English. The interview
Cross-cultural comparison of nurses’ ethical concerns 747
Nursing Ethics 2008 15 (6)
Table 1 Background data of participating Swedish (n = 21) and Chinese nurses
(n = 20)
Background variable Swedish nurses
13
Chinese nurses
12
Age (years)
Mean (SD) 37 (12.0) 33 (6.8)
Range 24–62 25–47
Civil status: no. (%)
Married/cohabiting 15 (71) 16 (80)
Living alone 6 (29) 4 (20)
Family members: no. (%)
a
2 or less 14 (74) 6 (30)
3 or more 5 (26) 14 (70)
Satisfaction with personal finances: no. (%)
a
Yes 16 (84) 15 (75)
No 3 (16) 5 (25)
Receiving help at home: no. (%)
a
Partner 9 (47) 12 (60)
Relative(s)/other(s) 3 (16) 8 (40)
Professional nursing education: no. (%)
a
Diploma 17 (89) 13 (65)
Specialist training 2 (11) 7 (35)
Academic nursing education: no. (%)
a
Bachelors degree 5 (26) 1 (5)
Years worked in neuroscience nursing
Mean (SD) 7.7 (9.2) 13.6 (7.6)
Range 0.5–31 3–30
Years worked in nursing
Mean (SD) 7.7 (10.4) 14.1 (7.3)
Range 1–41 6–30
a
Missing data from two Swedish nurses.
at Vaxjo Universitet on February 11, 2010 http://nej.sagepub.comDownloaded from

guides were the same in both countries with the exception of the language used
(Swedish and English, respectively) and consisted of the following questions:
1) What upsets you at work?
2) When do you feel displeasure at work?
3) What situations at work make you sad after a working day?
4) Do you experience ethical issues/dilemmas in your work? If yes, can you give
an example of a situation in which such an issue/dilemma appeared?
5) If yes to question 4, how did you try to cope with it?
6) How do you perceive the quality of nursing care in your unit?
7) Do you experience a discrepancy between the actual quality of nursing care at
your unit and the desirable quality?
8) If yes to question 7, how do you try to cope with this discrepancy?
9) What in the working environment is an obstacle to resolving ethical issues/
dilemmas in your work?
Additional follow-up questions were asked, their scope and number depending
on how precisely and fully the person had answered the general questions. The inter-
views were tape-recorded and typed verbatim, with pauses and expressions of emo-
tion included because these elements were considered important for understanding
the content. The typed texts were then analysed using qualitative latent content
analysis.
20,21
The theoretical assumption underlying qualitative content analysis is
based on communication theory. This analysis concerns the content and relationship
levels of communication. The words (content) also contain in them relationship
aspects such as attitudes or intentions. To uncover these aspects is the aim of the
interpretative process of latent content analysis. The analytical procedure and the
subsequent findings are described more thoroughly in the previous studies.
12,13
The second-order constructs – aggregated concept analysis
The analysis commenced with a reading of the findings of the two previous stud-
ies
12,13
to obtain a sense of the whole. Thereafter, the themes identified within each
content area of the empirical studies were compared. This process resulted in the
identification of both similar and differing themes among the Swedish and Chinese
nurses (Table 2). Where substantial similarities were found, a general theme was
extracted that would encompass and reflect the essence of the themes from both
countries. Where the themes in a content area differed substantially from each other,
a unique theme was formulated for the detected differences (Table 2). This synthe-
sis of the findings of the two previous studies
12,13
increased the level of abstraction,
which, according to Estabrooks,
18
leads to a more general understanding of the nurs-
ing phenomenon investigated.
Results of the aggregated and comparative analyses
The results are presented in the form of aggregated or common themes, incorporat-
ing similar empirical findings from both countries. The unique themes derived from
748 B Wadensten et al.
Nursing Ethics 2008 15 (6)
at Vaxjo Universitet on February 11, 2010 http://nej.sagepub.comDownloaded from

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TL;DR: Stress intervention measures should focus on stress prevention for individuals as well as tackling organizational issues, and will require further comparative studies, and new tools to evaluate the intensity of individual distress.
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Frequently Asked Questions (2)
Q1. What are the contributions in this paper?

Ahlström et al. this paper compare Swedish and Chinese nurses ' experiences of ethical dilemmas and workplace distress to deepen their understanding of the common and unique challenges nurses encounter in different cultures, focusing on the demanding field of neuroscience nursing. 

In both countries, the ethical dilemmas concerned seriously ill patients and the possibilities of providing good care.