NURSES WORKPLACE DISTRESS AND ETHICAL DILEMMAS IN TANZANIAN HEALTH CARE

Elisabeth Hggstrm, Ester Mbusa and Barbro Wadensten

Key words: ethical dilemma; phenomenological-hermeneutic; Tanzanian nurses; workplace stress The aim of this study was to describe Tanzanian nurses meaning of and experiences with ethical dilemmas and workplace distress in different care settings. An open question guide was used and the study focused on the answers that 29 registered nurses supplied. The theme, Tanzanian registered nurses invisible and visible expressions about existential conditions in care, emerged from several subthemes as: suffering from (1) workplace distress; (2) ethical dilemmas; (3) trying to maintaining good quality nursing care; (4) lack of respect, appreciation and influence; and (5) a heavy workload that did not prevent registered nurses from struggling for better care for their patients. The analysis shows that, on a daily basis, nurses find themselves working on the edge of life and death, while they have few opportunities for doing anything about this situation. Nurses need professional guidance to gain insight and be able to reflect on their situations, so that they do not become overloaded with ethical dilemmas and workplace distress.

Introduction
Nursing is a stressful occupation1 and Garner2 identified job stress as the strongest predictor of job satisfaction. An unsatisfactory work/personal life balance, an organization not focused on patient needs, outdated medical equipment, and insufficient development opportunities have led to rising levels of job stress for nurses.3 In addition, there is evidence to show that work overload and inadequate staffing, interpersonal relationships, and dealing with hospital administration are other major sources of stress.4 As Kitua et al.5 argue, the lack of trained staff, equipment, drugs and funds, and inadequate health care facilities, are among the top 10 health service problems in Tanzania. These can cause ethical dilemmas for health care personnel. Yet, people have the right to expect competent, high quality, ethical and personalized care from nurses and other health professionals. Ethical dilemmas in

Address for correspondence: Elisabeth Hggstrm, Brjegatan 19, 752 24 Uppsala, Sweden. Tel: 46 26 64 82 22; Fax: 46 26 648235; E-mail: elisabeth.haggstrom@hig.se

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Workplace distress and ethical dilemmas 479 nursing have so far been mainly related to the aggressiveness of treatment,6 and have not yet been systematically studied in Tanzania. A dilemma can be defined as a difficult problem seemingly incapable of a satisfactory solution, or a situation involving a choice between equally unsatisfactory alternatives.7 Studies about nurses job stress and ethical dilemmas have been conducted in developed countries, where health care systems are well structured and funded. However, little is known about nurses work experiences in developing countries with fewer resources, such as Tanzania. It is important, therefore, that nurses perceptions of their work experiences are questioned in these countries, and that factors that are considered stressful and affect their job performance are minimized. In the light of this, the aim of the present study was to describe Tanzanian nurses meaning of and experiences with ethical dilemmas and workplace distress in different care settings.

Method
Participants
Twenty-nine Tanzanian registered nurses participated in the study. They were all qualified, had practiced nursing for more than two years, and were from various health care settings. At the time of the study, these nurses had taken part in a continuing education program.

Data collection
Data were collected from written responses to open questions (as Tang et al.8) in order to gain insight into Tanzanian nurses views of ethical dilemmas and workplace distress, and lead to an understanding of the participants lived experiences. The role of the researcher when reading the informants written answers was to reflect on the question of how the nurses expressed their meaning about ethical dilemmas and workplace distress.

The phenomenological-hermeneutic approach

The text was analyzed using a phenomenological-hermeneutic approach inspired by the philosophy of Ricoeur,9 which has been used previously.1012 According to Ricoeur,9 lived experiences will always remain private and therefore it is not possible to express them to another person, although some meaning of experiences can emerge. The method implies that the researcher interprets the written answers in order to understand the informants experiences. The analysis is carried out in three steps, from nave reading to a structural analysis, and to interpretation of the whole. The nave reading and the results of the structural analysis are read in relation to researchers pre-understanding, and the questions that arise during the analytic stage are interpreted in the light of the text.13 The first and third authors pre-understanding stems from their background as Swedish registered nurses and researchers; the second authors background is as a Tanzanian registered nurse and teacher.

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Analysis
A process of open and critical reading and interpretation of the material was carried out throughout the structural analysis phase. The content of the meaning-bearing units, condensations, subthemes, and theme was read repeatedly, until the final subthemes and theme were established. The second author, who first made an independent analysis, performed a co-assessment. After this, the first and second authors discussed the subthemes and theme until they came to an agreement about what the names and the description should be. Finally, all three authors reached a consensus (Table 1).

Ethical consideration
The study was given approval by the Head of the Faculty of Nursing, Kilimanjaro Christian Medical College, Tanzania. Relevant information about the research was given verbally to the participants by the first researcher. Participation in the study was voluntary and the study followed ethical principles. It was stressed that the information would be kept confidential and that the participants had the right to choose whether or not to answer the questions.

Findings
Nave understanding
The Tanzanian nurses, who worked in several different departments, seemed to experience their work as mostly filled with difficulties. These included: feeling as though they fell short in their work because they had too many duties; the lack of equipment or defective equipment; and not having enough training or knowledge. Other difficulties that played a role in their daily work included lack of acknowledgement and understanding from their supervisors and even feelings of not being valued or of being disparaged by their supervisors and doctors. The nurses tried to make the best of the situation because they protect their patients, but every day they are forced to handle difficult decisions and ethical dilemmas because of the pressures of their work situation. This can negatively affect nurses self-confidence and self-reliance, and sometimes these difficulties even seemed to affect the nurses existential thoughts about themselves and their patients.

Structural analysis
In the structural analysis the main theme: Tanzanian registered nurses invisible and visible expressions about existential conditions in care situations emerged, together with the following subthemes: suffering from workplace distress, suffering from ethical dilemmas, suffering from trying to maintain good quality nursing care, suffering from lack of respect, appreciation, and influence, and suffering from a heavy workload that did not prevent the registered nurses from struggling for better care for their patients (Table 2).

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Table 1 Example of the analysis Condensed meaningbearing unit

One patient suffered because of having trouble breathing and then died due to the lack of equipment. Suffering from workplace distress

Meaning-bearing unit

Subtheme

Theme
Tanzanian registered nurses invisible and visible expressions about existential conditions in care situations

One patient died due to a shortage of equipment. He came to my unit with breathing difficulty. He needed immediate oxygen therapy but due to the shortage of oxygen, the patient had to struggle until he died. When the doctor in charge directed me to give first priority care to a person who is rich and to leave those people who do not have any money to give him to thank him for the health care. The nurse is invited/requested to give rich patients priority because they can pay the doctor some extra money Suffering from ethical dilemmas

Tanzanian registered nurses invisible and visible expressions about existential conditions in care situations

Workplace distress and ethical dilemmas 481

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Table 2 Subthemes and theme of the meaning of ethical dilemmas and workplace distress Subthemes
Suffering from workplace distress Suffering from ethical dilemmas Suffering from trying to maintain good nursing quality Suffering from the lack of respect, appreciation, and influence Suffering from a heavy workload does not prevent registered nurses from struggling for better care for their patients

Theme
Tanzanian registered nurses invisible and visible expressions about existential conditions in care situations.

The main theme (Tanzanian registered nurses invisible and visible expressions about existential conditions in care situations) arose from the authors interpretation of the subthemes (Table 2). The nurses expressed that ethical dilemmas and workplace distress arise because they have to work on a daily basis in conditions that have to do with the very existence of life. For example, the patients chances of survival and whether they obtain good care or die depend on what resources are available in a given situation. The nurses said they worry about their own health and their own lives because protective gear and equipment are often missing and, therefore, every day they risk serious infections. That the nurses sometimes have to prioritize rich over poor patients relates to both patients and nurses because of the fear of losing their jobs and not daring to protest about this. The meaning of ethical dilemmas and workplace distress was expressed by the nurses in different ways. Sometimes it is visible, such as when they officially try to demand change, for example, when they express their views to management and doctors. At other times it is invisible, such as their own thoughts about ethical dilemmas and workplace distress, which they do not share with others, but which instead gnaw at their consciences and create inner existential worries. Suffering from workplace distress Workplace distress appeared in all the nurses written texts, which was related to several different shortages in their workplace that result in inadequate care for patients and in feelings of guilt on the part of the nurses. The shortage of welleducated staff, especially nurses, and the insufficient number of nurses on duty during all work shifts make the nurses exhausted. When there are acute staff shortages the nurses often have to work 12-hour shifts against their will.
Sometimes I have to work from 8 am to 8 pm because of the shortage of registered nurses, although Im exhausted.

This could sometimes result in a nurse forgetting to give a patient a prescribed medicine and thus cause the nurses to feel guilty for not carrying out their job perfectly, despite that being their intention.
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I felt so bad when I remembered that I had forgotten to give the patient important diabetic medication and she had to suffer because of me.

On a daily basis, the nurses had to take care of many very sick patients and at the same time they always had to prioritize who would receive care first, because of the lack of resources. Several of the nurses stories also reveal how the shortage of equipment could result in fateful consequences. One patient died as a nurse watched and there was nothing she could do because the few available ventilators were all being used.
One patient died due to a shortage of equipment. He came to my unit with difficulty with breathing. He needed immediate oxygen therapy but due to the shortage of oxygen, the patient had to struggle until he died.

Education and continuing education were not available to these nurses, which caused feelings of discomfort and disinclination because they could not keep up with medical developments and use new scientific knowledge and proven methods to care for their patients. In the nurses daily work, they could give patients only the care that it was possible to give, even if this often meant a risk to their own health. Working with infectious patients without access to adequate safety equipment was experienced as very trying and the nurses always felt threatened by the possibility of becoming infected with a serious disease. Suffering from ethical dilemmas
My work as a nurse is also a risk situation for my life.

An ethical dilemma frequently described by the nurses was the difficulty in their daily work of protecting patients integrity and confidentiality. There was a lack of space where nurses could meet patients privately. Examinations, nursing care and conversations all took place in front of other patients. Secrecy was also unnecessarily broken by staff talking to unauthorized people and even to one another when it was not needed, especially about HIV diagnoses. The problem of HIV positive patients being stigmatized occurred frequently, according to the participant nurses. This ethical dilemma could have its origin in the lack of collaboration and knowledge about HIV positive patients because of which patients rights were often violated.
No confidentiality, especially for patients with HIV infections. After being diagnosed, some health workers exposed the results to other people. Stigmatization of HIV patients occurs.

The nurses also described how patients do not know about their own health care rights. This often causes staff to be careless about informing patients about occurrences of incorrect treatment and leads to nurses experiencing ethical dilemmas that they do not do anything about.
Patients must know their ethical rights. That is why most of the staff dont follow the ethical rules, because they know that no one will bother them.

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Ethical dilemmas also occurred when patients were valued and treated differently, depending on their social and economic status. The nurses were requested and encouraged by doctors to prioritize rich patients before poor ones. Some patients also offered the nurses payment to obtain faster and quicker health care. There were also bureaucratic difficulties in obtaining money from the government for needy patients so they could pay and receive adequate treatment in time. All the dilemmas concerning money and its relationship to what kind of care patients could obtain were experienced as unacceptable by the nurses, but they believed they had few possibilities of fighting against them.
When the doctor in charge directed me to give first priority care to a person who is rich and to leave those people who do not have any money to thank him for the health care, this situation made me feel bad and Im too afraid to fight for the patients rights.

Other ethical dilemmas occurred in care situations where nurses could not give patients the care they needed in time, when they had to choose who should receive care first and, in acute situations, when a quick decision had to be made. According to the nurses, an unsatisfactory solution to this was to delegate responsibility to someone who was not trained for it in order to solve the situation quickly.
One mother died during delivery because of a big bleed. She had to be transported to another department for surgery. I couldnt get the transport in time and the patient died. I felt so bad after that.

Suffering from trying to maintain good quality nursing care Although the nurses described an untenable work situation in terms of too few trained staff members for the number of patients and the lack of resources, they also talked about how they try to maintain good care for patients. These nurses are proud of their work and they described how they care for their patients and other staff, as one nurse expressed in the following quote:
I love my work. I love my patients and I feel for my staff. I feel very happy when my patients recover. I enjoy my work.

The quality of the care provided was described by the nurses as not bad. If the necessary equipment was available, the nurses thought that the quality of patient care would be acceptable. They try to make the best of situations and can be quite creative. They said they sometimes improvise with old-fashioned and unknown instruments.
For instance, we used to cut cords with larger blades instead of scissors, tethering the cord safely. The quality of the nursing care in my unit is not maintained to the highest standard, though I and the staff try to do our best to reach the standard expected according to the needs of our patients.

Staff members are not always interested in developing themselves and their work skills and some of them were described by the nurses as lazy and passive, leading

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Workplace distress and ethical dilemmas 485 to a worsening of quality. The reasons for this could be that the number of patients in relation to the number of staff is too high and the lack of resources makes staff lose their motivation for work, resulting in morale being negatively affected. The nurses sometimes think that the quality of the care provided is affected negatively because of the high workload and they said they can feel overwhelmed by the situation. Medical staff also experience frustration because of inadequate knowledge about the basic elements of patient care.
Everybody tries very hard to fulfill his or her duty despite the great number of patients in a ward or patients allocated to one nurse. I think, if possible, [the number of] patients per nurse should be reduced, otherwise we end up with poor quality care.

Care quality is also frequently affected by most of the patients inadequate knowledge about their illnesses and by some of them having trouble speaking the official language, Swahili. Suffering from lack of respect, appreciation and influence The nurses stated they experience inadequate respect for their work and their selfesteem, which is based on several factors. They described their supervisors as absent, sitting in their offices and not listening to and acknowledging nurses when they have problems. Often, the supervisors do not care if nurses talk about or want to be listened to regarding something that is difficult in their work, such as the staff shortage, too many patients, insufficient resources, the need for training, and the need for more qualified staff.
I think we lack the confidence or, I can say, the self-esteem to air out our views when there is a problem, due to the lack of appreciation from our superior.

Instead of being listened to concerning problems at work, the nurses described their supervisors looking down on them and often criticizing them for not doing a good job. If something has gone wrong, such as a patient complaining about his or her care, the nurse gets the blame rather than there being a thorough investigation into what has happened. Management was also described as favoring certain nurses, who then obtain advantages that others do not, such as receiving training or being promoted. Some nurses said they felt discriminated against because they are treated differently, which, according to them, is not fair.
It is when our leaders show favoritism among us staff members.

A lack of respect is also evident in doctors views of nurses and their work. Many doctors disparage or do not value the nurses skills and think that they do not know much about medicine and health care. The doctors think that the nurses should do only what they are told and should not question doctors prescriptions or put forward their own treatment suggestions for patients.
Some doctors dont trust what nurses do so I experience this in a very negative way. Doctors think that nurses know nothing.

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On several occasions, the nurses said they felt disparaged and questioned openly in the presence of patients, by both their supervisors and doctors.
When I performed my task well but a minor mistake happened, the supervisor criticized me in public. I felt so embarrassed although I was not guilty.

A common phenomenon was the nurses experiences of not being acknowledged by management. Although they worked hard and did their best despite unsatisfactory conditions with too few staff in relation to the number of patients, there was no praise.
No appreciation despite you trying to do much compared with the number of patients, supervisors do not appreciate what you do.

When asked what made work difficult, one replied:

When my supervisor demoralized me or failed to appreciate my work.

The lack of respect and appreciation made the nurses feel they had little influence in their daily work. When they tried to change and affect a care situation or an organizational problem, they were thwarted by both their supervisors and the doctors. This made them feel overwhelmed when they tried to change things for the better for patients. The nurses spoke a lot about how, in their daily work, they thought about what was best for the patients.
As I want to be a good nurse, I try to know about the patients feelings and I help the patients with understanding and sympathy. I tried so hard to get the doctor to understand that this patient needed more painkillers after his operation, but the doctor didnt listen to me and the patient cried and I couldnt do anything although everything was wrong for the patient.

Suffering from a heavy workload did not prevent the registered nurses from struggling for better health care for their patients The nurses described how they try to fight in various ways for better working conditions for the staff and better care for the patients. Everyone tries to involve their supervisors by seeking them out, writing to them, and inviting them to the department. The nurses commented that all hospital management personnel should work towards employing more well-trained nurses and even increasing their salaries.
I try to convince the hospital matron to refresh the staff or recruit more, to plan and provide good nursing care for our patients, involving patients in planning their care and in decision making. Salaries are not enough and life is very tough.

According to the nurses, a new phenomenon is that many of them quit their jobs and move out of the country in order to get a chance to work in better conditions, to be able to give good and safe care, and to receive an adequate salary. This situation was described by the nurses as very serious and they are fighting to obtain
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Workplace distress and ethical dilemmas 487 better work conditions and better status by officially calling attention to their situation in meetings and at conferences. The nurses stated that they have many good strengths among them, and they want to continue to work in Tanzania and improve care for patients.
Some registered nurses who have the possibility often those without children move abroad for some years in order to learn a lot and to earn enough money for living. I feel that the government of Tanzania has to work on it.

In order to develop and improve patients care, the nurses talked about how they try to educate staff by discussing care and showing how it should be done. Sometimes, nurses arrange short training sessions in the department in order to raise standards. The difficulties with this are that everyone works long shifts and that there is no money to pay for overtime. Despite this, they put in a lot of effort so that staff training can be improved. They also try to undergo training themselves, just as they encourage their staff to do. One participant described how she tries to improve herself and her staff:
By including seminars, clinical conferences, and continuing education in order to update my knowledge to get to my desired level in patient care.

The nurses also talked about how they try to encourage and convince staff members to think positively about their work. They say that the situation is very difficult and serious, but that they have to work for change and try to concentrate on positive changes and situations each day. In this way, the nurses work towards the long term to improve their own and their staffs attitudes towards their work. They do this because they are thinking of their patients right to good health care.
Emotionally, you feel pity but we cant just sit back pitying ourselves without acting. Therefore, I think we should deal with what there is and work hard to rise up, as I dont believe in giving up.

Discussion
The aim of this study was to describe a group of Tanzanian nurses experiences with ethical dilemmas and workplace distress in different care settings. The results plainly show that these nurses find themselves in a very difficult work situation, as indicated by the overarching theme of: Tanzanian registered nurses invisible and visible expressions about existential conditions in care situations. The nurses expressed that ethical dilemmas and workplace distress come from having to work on a daily basis in conditions that have to do with the very existence of life, which can affect nurses both at work and in their private lives. This can be compared with the Swedish situation with regard to municipal health care for elderly people, where staff have been shown to be affected both at work and privately by the ethical dilemmas they experience in wanting to give the care required, but are unable to do so because of lack of time and they then place the blame for this on themselves.12 The Tanzanian nurses felt inadequate at work because there are too few staff, the staff are not educated well enough, and there is insufficient equipment, a lack of
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protective gear and equipment, and too many patients in proportion to the number of nurses. Hertting et al.14 and Olofsson et al.15 showed in their studies that health care personnel are negatively affected by having too many patients and work duties in proportion to the number of staff, which can lead to the staff becoming stressed and thus to a worsening of the quality of the health care provided. A similar situation of lack of educated staff and of resources has been described regarding nurses work in China.8 However, the Tanzanian nurses, more so than the Chinese nurses, emphasized the lack of protective gear and equipment, describing their belief that their lives are in danger because of this combined with the serious infectious diseases they come into contact with on a daily basis.8 The Tanzanian nurses meaning of and experiences with ethical dilemmas and workplace distress also have to do with the lack of appreciation from both their supervisors and doctors. They talked about unfair treatment and being blamed for situations that went wrong without having the chance to defend themselves. They also describe how doctors look down on them, disparage them or do not value their knowledge, and do not listen to them when they try to give suggestions for patients care. As in other reports, this study shows that the participant Tanzanian nurses do not receive sufficient information about patients treatment and that they are not part of the process of making decisions about changes to patients treatment.1618 Problems of this type do not differentiate between how Chinese and western nurses describe their opportunities for being part of and being able to affect patients health care.8,19 Chinese nurses have described how they feel like doctors assistants,8 which can be compared with the Tanzanian nurses, who frequently described how doctors view them as ignorant and think they should just follow doctors orders. A big problem for the Tanzanian nurses is that sometimes doctors encourage them to prioritize rich patients before needy ones because doctors accept bribes from those who can pay to receive better health care. This phenomenon has not been described in other studies and therefore may possibly be considered unique to Tanzania.19 This causes difficult ethical dilemmas because the nurses have difficulty saying no to doctors because of their fear of reprisals, and at the same time they want to help all patients who need health care, regardless of their financial situation. This can be compared with western health care professionals views on how financial factors and evaluations affect patients health care when financial factors take precedence over humanistic ones.20 Despite their difficult work situation, the participant Tanzanian nurses tried to do their best for their patients, usually saying that they like their patients and that they even like their work. In the present study, the in-depth analysis of the Tanzanian nurses work situation showed that, on a daily basis, they find themselves working on the edge of life and death, while they have few opportunities for doing anything about this situation. As nurses in the west, they have been trained to educate others to care for the weak people in society21,22 and they therefore experience frustration with their current work situation. This is an ethical dilemma in which these Tanzanian nurses want to live up to the demands placed on them that is, to give patients good care but this is often impossible because of the circumstances. This results in feelings of frustration and low levels of self-confidence and self-reliance. Buber23 describes the meeting of a person being cared for and the person caring for him or her; for these Tanzanian nurses, this would be a mutual and vulnerable exchange in which they

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Workplace distress and ethical dilemmas 489 would be acknowledged in their work roles. However, this acknowledgement cannot occur when the opportunities for giving good care are reduced, and this results in their low self-esteem and their experience of often finding themselves in situations of ethical dilemmas and existential difficulties.24,25 These difficulties can be both visible and invisible, as expressed in this studys overarching theme: Tanzanian registered nurses invisible and visible expressions about existential conditions in care situations.

Methodological considerations
A phenomenological-hermeneutic method was used for this study. Generally, narrative interviews would be used, but in this study the researchers chose to use a question guide with open questions. This was so that the Tanzanian nurses could answer the questions in peace and quiet, without having to think about speaking English well. According to Ricoeur,26 the starting point for analysis is the written text. When the text is analyzed, it is the researchers interpretation that is emphasized. In this study, the meaning attributed to ethical dilemmas and workplace distress in care was analyzed. This is one of several possible interpretations that should be seen in relation to the deeper meaning of the Tanzanian nurses ethical dilemmas and workplace distress. The nurses wrote long, comprehensive responses to the open questions, and similarities in what became this studys deeper interpretation were found in all the texts, which strengthens the studys trustworthiness.27 The small number of participants in this study (n 29) does not allow the results to be generalized, although they could increase understanding in supervisors and nurses who work in health care in Tanzania, and even for others in similar situations.26

Conclusions
No authors of previous studies have reported on the issue of ethical dilemmas and workplace distress experienced by Tanzanian nurses in health care situations. The present study therefore contributes new knowledge to this field. The findings showed that Tanzanian nurses are in a difficult work situation and that they need help and support in the form of being seen and acknowledged at work. This requires more educated staff, more support to be given by supervisors who are present in the work situation and who acknowledge nurses, and a more positive opinion from doctors. Other factors that need to be improved are better equipment for patients and better protective gear and equipment for nurses. Another conclusion is that these nurses need professional guidance so that they can achieve insight into and reflection on the situations they are in, while also being made conscious of the fact that they do not have to overload themselves with ethical dilemmas and workplace distress.28

Acknowledgements
The authors wish to express their gratitude to the Faculty of Nursing, Kilimanjaro Christian Medical College, and to the University of Gvle, for taking part in the

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Linnaeus Palme scholarship exchange. Further appreciation is given to the Tanzanian registered nurses who participated in this study. For linguistic revision, our thanks go to Brett Jocelyn Epstein. Elisabeth Hggstrm and Barbro Wadensten, University of Gvle, Gvle, Sweden. Ester Mabusa, Kilimanjaro Christian Medical College, Tanzania.

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