Article

Nursing Ethics
2015, Vol. 22(5) 548–560
Some ethical conflicts ª The Author(s) 2014
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in emergency care 10.1177/0969733014549880
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Maria F Jiménez-Herrera
Rovira i Virgili University, Spain
Christer Axelsson
Högskolan i Borås University, Sweden

Abstract
Background: Decision-making and assessment in emergency situations are complex and result many times
in ethical conflicts between different healthcare professionals.
Aim: To analyse and describe situations that can generate ethical conflict among nurses working in
emergency situations.
Methods: Qualitative analysis. A total of 16 emergency nurses took part in interviews and a focus group.
Ethical considerations: Organisational approval by the University Hospital, and informed consent and
confidentiality were ensured before conducting the research.
Result/conclusion: Two categories emerged: one in ‘ethical issues’ and one in ‘emotions and feelings in
caring’. The four ethical subcategories are presented: Autonomy, the first sub category: first, the nurse’s
ability to practise care on an emergency ward and, second, to support the patient and/or relatives in
terms of care and medical treatment. The conflicts arise when the nurse ends up in the middle between
the patient and the physician responsible for the diagnosis and treatment from a nature scientific
perspective. Reification of injured body: patient was often reified and fragmented, becoming just a leg or
arm. Different factors contributed in this perspective. Pain: pain relief was often inadequate but more
effectively treated in the emergency medical services than at the emergency department. The nurses
highlighted the phenomenon of suffering because they felt that pain was only an object, forgetting the
patients’ care need, like separating mind from body. Death: the nurses felt that the emergency services
are only prepared to save lives and not to take care of the needs of patients with ‘end-of-life’ care.
Another issue was the lack of ethical guidelines during a cardiac arrest. Resuscitation often continues
without asking about the patient’s ‘previous wishes’ in terms of resuscitation or not. In these situations,
the nurses describe an ethical conflict with the physician in performing their role as the patient’s
advocate. The nurses express feelings of distress, suffering, anger and helplessness.

Keywords
Advance life support, caring, ethical conflicts, emergency department, nurses

Corresponding author: Maria F Jiménez-Herrera, Department of Nursing, Rovira i Virgili University, Avgda. Catalunya, 35, 43002
Tarragona, Spain.
Email: maria.jimenez@urv.cat
Jiménez-Herrera and Axelsson 549

Introduction
Urgent and emergency care is defined as a reality that cannot be compared with the rest of hospital care
services. These services have some essential and specific characteristics which make them different from
the rest; they must be prepared for emergency missions 24 h a day, 365 days a year, so there is no possible
programme for the activity. A patient calling 112 or seeking help at the emergency department (ED)
demands attention which the care teams have to provide. Decision-making in emergency practice is often
a complex process.1,2 Decisions are made about specific situations that appear as a result of the demand.
These situations often include a series of ethical conflicts that need to be taken into consideration.
Technologically and scientifically, urgent and emergency medicine has developed during the last few
decades. Some situations, such as cardiac reanimation or mechanical ventilation, were previously impossi-
ble to perform, but nowadays they are easily resolved. However, we must not stop considering the risks and
complications.3,4 Healthcare staff often find themselves in situations where a reflection and a decision is a
process between different disciplines, such as law, philosophy, anthropology and not just medicine and
nursing.
Nurses in emergency care need to reflect on the action they take during their everyday work in order to
improve their knowledge of caring activities.5 However, the ethical discourse must work in the nursing pro-
fession by discerning the professional help they have to give, contributing care such as that a professional
offers in the healthcare setting and not from other disciplines. Studying and extending the ethical aspects in
care practice will help nurses to learn more about their own discipline and contemplate the reality through
interactions between individuals as protagonists of the facts.6,7
Nursing, as a profession, has always searched for a way to develop its work in the pursuit of good deeds
and to introduce innovations to consolidate professional independence. As a profession, nursing has been
the subject of debate for a long time, and authors like Watson8 and Tanner9 have focused on the need for
nurses to define their own identity. The autonomy of nurses is continuously disputed because it challenges
other professionals.
Nowadays, when nurses talk about ethics in their profession, they do not attempt to introduce concepts of
what is good or bad into nursing discourse. Instead, they attempt to learn from the caring situation,10 from
the patients’ needs in situations that are often only evaluated from a biological point of view. The nurse has
to guide the patient through important questions and changes in life, both technological and social, such as
life, death, relationships between people, environment, biotechnology and genetics. The nurses can find
tools for caring when they combine their practical knowledge with an ethical approach.11

Aim
The aim of this research was to analyse and describe situations that can generate ethical conflict among
nurses working in emergency situations.

Method
Organisation
In this study, we chose nurses working at the ED or/and in the advanced life support (ALS) ambulance.
Nurses were selected for having experience in emergency care, both outside and inside hospital. The char-
acteristics of the care teams in the ALS unit are one nurse, one physician and one ambulance technician. At
the ED, the nurses often work in different teams and with different nurses and physicians during his or her
shift. The vast majority of nurses working in ALS ambulances usually also work at the ED.
550 Nursing Ethics 22(5)

Table 1. Characteristics of informants.

Age Years of Participation

No. Code (years) Gender Education experience Field (interview) Participation (FG)

1 ENF1 32 Female Nurse 8 Pre-hospital/hospital Interview ***

2 ENF2 35 Female Nurse 14 Pre-hospital/hospital Interview FG
3 ENF3 41 Female Nurse 20 Hospital Interview FG
4 ENF4 47 Female Nurse 22 Hospital Interview FG
5 ENF5 36 Female Nurse 16 Pre-hospital/hospital Interview FG
6 ENF6 36 Female Nurse 15 Pre-hospital/hospital Interview FG
7 ENF7 41 Female Nurse 22 Hospital Interview FG
8 ENF8 35 Female Nurse 16 Pre-hospital/hospital Interview ***
9 ENF9 42 Female Nurse 21 Hospital Interview FG
10 ENF10 35 Female Nurse 17 Pre-hospital/hospital Interview FG
11 ENF11 45 Female Nurse 23 Hospital Interview FG
12 ENF12 27 Female Nurse 6 Pre-hospital/hospital Interview ***
13 ENF13 31 Female Nurse 12 Hospital Interview ***
14 ENF14 41 Female Nurse 19 Hospital Interview FG
15 ENF15 36 Female Nurse 15 Pre-hospital *** FG
16 ENF16 28 Female Nurse 7 Pre-hospital/hospital *** FG

FG: focus group. ***: no participation.

Data collection
We used a qualitative methodology, involving 16 nurses aged 27–47 years. Seven nurses worked at the ED
in a referral hospital in a local area, one nurse worked in the ALS unit and eight nurses worked both in the
ALS ambulance and at the ED. We regarded all nurses as experts according to the rating made by Benner12
because their average years of experience were 16.86 years, ranging from 6 to 23 years in their speciality.
During the study period, only two male nurses worked at the ED, none in the ALS unit. None of the male
nurses wanted to take part in this study.
In Table 1, the participants’ characteristics are given, together with years of experience and the way they
participated: interview and/or focus group (FG). Both tools were used for collecting data. In order not to be
limited in time, the interviews and focus-group meetings took place during leisure time and in comfortable
places, out of hospital and away from the ambulance, which gave the informants privacy.
All nurses participating in the study were invited to participate in interviews and in the FG; 14 of 16
nurses took part in the interviews and 12 of 16 confirmed their participation in the FG. The principal inves-
tigator interviews the 14 nurses. These interviews can be defined as ethnographic, informal, focalised and
semi-structured in order to capture what people say and do and why they do it. Each interview took around
90 min. To organise these interviews, a question guide was created.
Of the 16 nurses, 12 took part in a FG, 6 ED nurses and 6 ED/ALS nurses. The aim was to use inter-
action data from the interviews to increase the depth and reveal aspects of the phenomenon assumed to be
otherwise less accessible. The FG managed by an expert in group dynamics. For the session, she used
specific guidance notes from the interviews where different themes were grouped. The guidance notes
also included some questions to explore systematically and increase the group dynamic. This technique
has helped us to obtain information and discuss the following subjects in depth: knowledge, attitudes,
feelings, beliefs and, in particular, experiences that would not have been possible by only conducting
individual interviews. The information generated from the interviews and FGs was digitally recorded and
transcribed verbatim.
Jiménez-Herrera and Axelsson 551

Ethical
Isuues
Autonomy

Reificaon
of injured
body

Pain

Death

Figure 1. Ethical issues.

The analysis was carried out according to the qualitative content analysis. Content analysis defines itself
within this framework as an approach of empirical, methodological controlled analysis of texts within their
context of communication, following content analytical rules and step-by-step models, without quantifica-
tion.13 From this perspective, the reading, organisation and interpretation of data were categorised in order
to obtain a result, focusing on the ethical conflicts that appear in the process of the text analysis. Based on
the context (ED and emergency medical service (EMS) care), the analysis of the categories gave a meaning
to the reality in different situations.

Ethical considerations
In order to recruit informants, a group of nurses from the ED and the EMS were asked to participate in the
research project. The nurses participated on a voluntary basis and were reassured of data confidentiality, as
well as anonymity. Data from the transcripts of interviews and FG were collected according to the Law 15/
1999 of Protection of Personal Data. All the informants had the opportunity to leave the study whenever
they wanted and had to sign a document of informed consent. The research project was piloted and approved
by the ethics committee at the reference hospital.

Results
We found two categories: ‘ethical issues’ and ‘emotions and feelings in caring’. The category ‘emotions and
feelings in caring’ does no answer to the aim of this article when it is more focused on the caring processes
and do not respond to ethical conflicts of the same nature.
This result will only deal with the ethical issues including the following subcategories: ‘Autonomy’,
‘Reification of injured body’, ‘Pain’ and ‘Death’ (Figure 1).
552 Nursing Ethics 22(5)

Autonomy
For the nurses participating in this study, two dimensions related to the concept of autonomy were clearly
defined. First, the perspective of the professional autonomy of nursing in the care of the patient. Conflicts
arise in emergency situations when the nurse and the doctor did not share the same paradigm and when the
nurse felt that she was ending in the middle between the patient and the doctor. It usually occurs in situations
when the solution for the patient was only based on a biomedical perspective but, according to the nurse,
required a more integrative model from a holistic perspective. The nurse felt in these cases without auton-
omy to exercise their professional role. And second, the autonomy of the patient in decision-making in
terms of medical care and treatment in emergency situations.

Reification of injured body

Nurses feel that the patient, assisted in critical situations at the ED, often are reified and fragmented to a num-
ber or a disease. To become a leg, an arm or an injured heart, depersonalise and dehumanise the caring process.

Pain
The nurses point out that pain relief in urgent and emergency care is a technical issue that has not been effec-
tively resolved and, further, that the approach to pain changes, depending on the situation and the type of pain.
Sharp pain is most often regarded as a central aspect and therefore has priority over other problems that
may arise. However, pain often makes the team forget the holistic perspective.
Nurses indicate that there are differences in the treatment of pain prescribed in the EMS care when com-
pared with the ED. They note that pain relief with analgesics is more effective, in terms of doses and med-
ication, when treated by EMS.
Another issue that concerned the nurses was the depersonalisation of the phenomenon of suffering. Pain
only appears to be an object to treat and control, while forgetting the patients’ care needs, like categorising
mind and body separately.
The interviews confirmed that the doctor often prescribes less effective analgesics than needed (e.g. per
os instead of intravenous administration) and that nurses often change the prescribed doses. The problem is,
according to the nurses, that the patients do not demand enough care because of the pain they are suffering.

Death
When a patient with ‘end-of-life’ care feels that death is approaching, he or she often calls for the emergency
services. In this situation, nurses are distressed because they do not think the emergency services are pre-
pared to perform end-of-life care, neither in support nor in treatment. The ED and the ambulance are places
equipped for resuscitation and not to take care of patients with ‘end-of-life’ care.
Another issue the nurses want to enhance is the performance when a cardiac arrest occurs. They
describe aspects related to making decisions about initiating resuscitation or not. In many cases, resusci-
tation continues without asking the family or relatives about the patient’s previous wishes regarding
resuscitation or not. Inside hospital, the physician usually makes the decision, but outside hospital, the
nurses are involved. In spite of this, they still find many occasions on which resuscitation is started with-
out ethical considerations.
The nurses highlight the need for ethical guidance in extreme situations, when there is no chance of
recovery. They feel that the patient in the clinical practice is treated according to pathological and clinical
aspects and that the ethical dimension often is forgotten. Most often, these patients die, with large-scale
interventions from a technical and pharmacological point of view.
Jiménez-Herrera and Axelsson 553

In the above-mentioned situations, the nurses describe an ethical conflict with the physician when it
comes to performing their role as the patient’s advocate, to do what is best from an ethical perspective; the
nurses express discomfort with feelings of distress, suffering, anger and helplessness in these situations.

Discussion
Autonomy
In relation to the autonomy of the nurse, we found that the relationship between physicians and nurses is
sometimes strained, the reason is to be found in the different views of the same situation.14–16 The nursing
perspective is to take into account the different dimensions including emotions and feelings, which tradi-
tional natural sciences have difficulty to respond to. It is about the interface between the biological and the
social dimension, as the patient reconciles the lived body with the object body in the experience of illness.17
One example of this is when the physician actively intervene only the cause of the disease from diagnoses
and symtoms18 while the nurse wants to focus more about the patient and his or her knowledge of his or her
illness and rehabilitation. The nurses feel that they should be the advocate for the patient and his or her ill-
ness19–21 and feel frustration in these situations.
The sources of this conflict have also been identified by LeTourneau22 with two similar reasons: (1) the
power imbalance between nurses and physicians and (2) the different goals of medicine and nursing.
To implement interdisciplinary collaboration, it is important to recognise these conflicts and perform
goal communication between both professionals. Different studies report the same interdisciplinary con-
flicts23,24 in healthcare situations, such as operating room or intensive care, where teamwork is manda-
tory.25–27 We note these conflicts from our informants, and one nurse says, ‘No, don’t ask. They only
want you to say that they are doing well’ (ENF3 [8]).
There are many differences between physicians and nurses, but the most visible are the power that med-
icine has. Traditionally, the profession of medicine has emphasised expertise, autonomy and responsibility
more than interdependence, deliberation or dialogue.15 ‘[ . . . ] No, no they do not anticipate with us. If they
did, things would go differently, this is my experience. You can say what you think, argue, but it is useless
because you can’t change their views’ (ENF10 [9]).
On the other hand, patient participation in nursing care and medical treatment is a legal right in Spain.
Different studies have established that patient participation is very important28 for recovery. This position is
also defended by the Spanish Emergency Nursing Society.29
In the field of emergency care, the basic principles of ethical autonomy are frequently ignored. Further-
more, one example is the information to the patient. In many cases, the patient has not been informed about
the treatment or is replaced by the family, even when he or she is able to make decisions independent of the
situation.
Normally, when making decisions in these situations, it is necessary to consider two aspects: clinical pro-
cedures and how they relate to the patient. In the emergency field, you most often only consider the first.
Normally, in emergency situations, the decision is preceded by factors such as time, the inability to assess,
unconsciousness, absence of family and life-threatening situations. However, in many situations, the
patients are able to decide. In this study, the nurses affirm that the patients rarely make emergency decisions,
even if they are allowed to. Sometimes, the family makes decisions, but most often the decisions are made
by the emergency physician:

[ . . . ] the family most often doesn’t understand the information or what is happening. Often you explain the sit-
uation and many other things to them, but after a while you realize that they haven’t heard anything . . . then you
realize that they don’t understand. It’s difficult . . . (GF10 [24])
554 Nursing Ethics 22(5)

Reification of injured body

In actual fact, the developments in medical science and technology have forced us to abandon the concept of
the ‘natural’ human body. New technological advances have made far-reaching interventions possible,
extending the boundaries of a single body beyond its skin, tissues and organs. Human beings have become
an assembly of body parts, and this development has raised new perceptions of this.30
We can describe three paradigms of healthcare that heavily influence contemporary care: they are known
as the technocratic, humanistic and holistic models of medicine.31 The technocratic model (TM) stresses
mind–body separation and sees the body as a machine; the humanistic model emphasises mind–body con-
nection and defines the body as an organism; the holistic model insists on the oneness of body, mind and
spirit and defines the body as an energy field in constant interaction with other energy fields.32
Some tenets of the TM are mind–body separation, such as the body as a machine and the patient as an
object. Acting on this model, there is no need to engage with the individual who inhabits that body, prefer-
ring instead to think of and talk about a patient as ‘the cardiac arrest’ or ‘the broken leg’. However, many
nurses realise that the humanistic/holistic approach is very important and in the interviews they say,

[ . . . ] Being with the patient, being attentive to his/her concerns, related to the family. I get the impression that the
nurse is like a link between the medical world and the world of the person. I am not saying that technology isn’t
important, but caring means protecting the person, and knowing his or her needs [ . . . ]. (ENT7 [1])

Other tenets of TM are the super-evaluation of the technology and aggressive interventions with the
emphasis on the short term. Many people feel that diagnostic tests and more sophisticated machines over-
come the serious health problems of people, but we must not forget that the ethical use of these machines is
very important because the inappropriate use of technology leads to the denial of the patient. In emergency
situations, it is necessary to act quickly to resolve the problems that threaten life, even if it is necessary to use
high technology. Accompanying the patients in these situations is the role of the nurse:

[ . . . ] In emergency situations, there are many things that do not seem important at that moment but are . . . – for
example, a patient was panicking, because of dyspnea, and I grabbed his hand during the time and before the
medicine had an effect. Afterwards, when the person felt better, he thanked me for helping him handle the sit-
uation [ . . . ]. (ENF9 [2–3])

We cannot ignore the technological advances that are being made with advancing science, but the tech-
nocratic paradigm limits the patient and turns him or her into a machine, an object to be repaired by
changing parts. It also dehumanises the caring relationships and hides other personal needs. It is the
nurse’s role to bring the humanistic and holistic paradigm into emergency care, both paradigms have
important contributions to make to medicine complementing the technocratic paradigm. A merger could
generate a new understanding of the relationships between professionals and patients because the two
paradigms bring us closer to the patient as a subject and therefore help us to use concepts like compassion
and sensitivity. For the emergency-care professional, it will be very important to understand that it is nec-
essary to combine both models.

Pain
Pain is an unpleasant experience that affects every human being at some point in his or her life. In spite of
scientific and technological advances, the treatment continues to be inadequate, in many cases. Pain is one
of the most common symptoms that are treated in EDs, as well as in the pre-hospital field. There are numer-
ous studies that suggest that pain management is inadequate for various reasons, in the late 1980s, Oden33
Jiménez-Herrera and Axelsson 555

analysed the barriers to effective pain management and found three main headings: lack of knowledge, bad
attitudes and methodological difficulties; other studies confirm these claims.34,35
In spite of a wide range of therapeutic opportunities, pain is a serious welfare and ethical problem. Due to
the inherent subjectivity of pain, assessment and treatment are influenced by bias and emotions.36 Ferrell
talks about the triple-whammy effect:37 the doctor prescribes quantities below what is necessary, the nurses
administer less than prescribed and patients do not report their pain fully. In previous research, the nurses
experience pain relief as an ethical dilemma:

. . . Too low doses of pain relief are often prescribed, but some nurses do not insist on more, even if they see that
the patient is still suffering. We see this every day; if you are unlucky and get the wrong nurse, you will suffer
from pain . . . (GF: R5 [8])

The American Pain Society (APS) with other organisations declared officially that the pain is ‘The Fifth
Vital Sign’. Henceforth, the evaluation of pain will become a requirement of proper patient care in the same
way as the assessment and management of temperature, blood pressure, respiratory rate and heart rate.38
The society regards pain relief as the basis of a fundamental human right. For this reason, the World Health
Organization (WHO) is urging governments to ensure access to opioids for pain.
In this study, the nurses point out that the treatment strategies in the ambulance are more suitable and
comfortable for patients than those in the ED. The reason for this could be that the pain is perceived differ-
ently and much closer to the emergency teams than the hospital professionals, and, on the other hand, when
they assist a patient, they normally have one and all their time can be devoted to him or her. This is very
different in the ED, where the nurse needs to take care of more patients at the same time:

R6: I think that nurses are more sensitive to what happens to the patient than other professionals.
R8: The nurses are closer to the patient.
R2: In emergency situations, everyone is clearer about how to use the analgesic drugs, but, if the same patient is in
hospital, the same doses are minimized or forgotten. I don’t understand why . . . (GF [7])

The issue of pain has, however, only been addressed to a limited degree by bioethics, probably because of
more ‘hot’ topics like abortion or euthanasia. Pain relief is a forgotten practicality that needs to be applied to
patients almost every day. Edwards et al.39 suspect that the demotivation for these studies is based on the
fact that pain is a bedside symptom in which the physicians, who have the basic knowledge, have been par-
tially disinterested.
It is unethical for a person to suffer from unbearable pain when there are mechanisms, both chemical and
physical, which can be effective in controlling pain. Delvecchio et al.40 strongly criticise biomedicine, stat-
ing that it contextualises the pain, separating the person from his or her disease at different levels. In this
respect, one informant says,

. . . The person cannot be separated from his or her suffering and pain; you cannot separate pain from the rest of
your body. In this situation, you become so small, so small . . . (GF: R1 [9])

Death
Talking about death in the ED is always a controversial issue, especially when a hospice patient arrives with
the only aim of dying. Terminally ill patients in the ED sounds like a contradiction because this type of care
seeks to treat symptoms and bring comfort to the patients. In the ED, the goals are resuscitation, patient
stabilisation and disposition – either to a hospital ward or back into the community.41 Attention should
556 Nursing Ethics 22(5)

instead focus on promoting quality of care and the dignity of the dying person. One of the important things is
the appropriate context; the emergency service is characterised by a very high flow of patients, fast work
with limited diagnostic and therapeutic decisions made by young professionals and end-of-life care
demanding time, space and restrictions (e.g. no cardiopulmonary resuscitation (CPR)).42
In an attempt to give a response to this question, we think that death is inconvenient from a social, sci-
entific and technological perspective. From every perspective, death is a loss or a failure. People do not want
to talk about death because it is painful and includes many questions. Death often abruptly changes the sit-
uation for the living. For the professionals in the emergency team, death is a failure.
The complexity of death is extensive from the cultural and the biological perspectives. The process of
death and the care at the end of life have been studied by many authors and according to different sciences.
The concept of death changed during the 1950s, when we learned reanimation using CPR. This knowledge
opened the door to other ways of understanding death and could be split into two stages: clinical death and
biological death. During clinical death, there is a time window of 10 min when it is possible to start CPR
and, if effective, reverse death.
In the following decades, many clinical situations appeared, when it became difficult to decide whether
or not to reanimate, such as in vegetative states, when the potential for recovery was not clear from a legal
point of view. This situation started ethical discussions, suggesting limits for the continuity of life
support.4,43,44
When a person suffers a cardiac arrest, the principal question is whether or not to start resuscitation.
Before starting or continuing CPR, some medical and ethical aspects must be taken into consideration.
However, the reality is often more difficult in an emergency with different situations and with a lack of trust-
worthy information:

[ . . . ] They say that the patient had a cardiac arrest for a long time, which we also suspected but no one has seen
. . . Shall we start CPR or not? If we start, will we resuscitate the patient to a good life or not? The decision has to
be immediate and you never know if the right decision is to start or not. (ENF12 [8])

In some cases, the obstinacy of professionals leads to therapeutic obstacles, to treat conditions, regardless
of the result. If the professionals ask the patient and their families, when possible, many of these situations
could be avoided. These situations for health professionals and especially for the nurses in our study cause
feelings that are often called moral stress:45

[ . . . ] I think if they heard me, things would have been different, it’s my own experience. When you see how
people are after these situations, you get angry, you discuss things with your colleagues but . . . and seeing the
patient lying in this way, I would prefer that, if I have a cardiac arrest, please do nothing . . . (ENF10 [9])

Making a decision about starting, or not starting, resuscitation is always an act of how to perform a treat-
ment. For the emergency-care professionals, it is difficult to not start because they are only trained to save
lives by performing different interventions. However, in many cases, it is easier to start resuscitation and
cease when the situation is more clear. Ågård et al.46 suggest that there are several psychological reasons
that drive professionals to start CPR manoeuvres and justify initiating manoeuvres to assure close relatives
and bystanders that everything possible has been done and that their efforts were commendable.
Emergency-care professionals sometimes have difficulty understanding that ceasing resuscitation is also
an action because all actions are designed to achieve the best for the patient. In a resuscitation scenario time
and information is often limited, to start resuscitation by time for collect information and take further deci-
sion in the situation.
Professionals should understand these premises because defending life above all, in many cases, leads to
the perpetuation of the idea that people cannot die and are denied the right to do so. Emergency-care
Jiménez-Herrera and Axelsson 557

professionals should be aware of how important it is to let people die with dignity taking into account the
complexity of the term and what it means in the context of emergencies. The influence of these thoughts
could help by motivating change in this important sphere of clinical practice.

Limitations
Qualitative studies, by their nature, do not attempt to generalise findings. The results of this study can only
be regarded as representing the meanings and the experiences of the participants. This research study was
carried out only with females, and the researchers acknowledge that maybe different findings may be
revealed if the study included male nurses and a larger number of participants.

Conclusion
The present result focuses on the category ‘ethical issues’ with the four subcategories: ‘Autonomy’,
‘Reification of injured body’, ‘Pain’ and ‘Death’.

Autonomy
According to ‘Autonomy’, two themes emerged. First, the nurse’s ability to practise care on the emergency
ward, and second, to support the patient and/or relatives regarding care and medical treatment in emergency
situations. Being an advocate for a patient from a humanistic/holistic perspective requires time, so that trust
is built up between the nurse and the patient. The conflicts arise in urgent situations when the nurse ends up
in the middle between the patient and the physician who is responsible for giving the diagnosis and only
treats the patient from a biomedical perspective.

Reification of injured body

Nurses feel that the patient, when assisted in critical situations, is often reified and fragmented, becoming
just a leg or an injured heart. The reason for this is probably to be found in organisational factors, the mod-
ernisation of interventions and guidelines. From this perspective, care becomes impersonal and unkind,
making it difficult to practise from a humanistic/holistic and integrated angle.

Pain
The nurses point out that pain relief in urgent and emergency care is a technical issue that is not effectively
resolved. They note that pain relief with analgesics is more effective, in terms of doses and medication,
when treated by emergency service rather than ED. Another issue that concerned the nurses was the deper-
sonalisation of the phenomenon of suffering and the support that the patient needs in that situations. Pain
only appears to be an object to treat and control, forgetting the patients’ need for care, like categorising mind
and body separately.

Death
Patients with ‘end-of-life’ care often call for the emergency services. In this situation, nurses are distressed
because they feel that the emergency services are only prepared to save life and not to perform ‘end-of-life’
care, neither in terms of organising care nor in treatment. Another issue is the lack of ethical guidelines dur-
ing a cardiac arrest for guiding these situations. In many cases, resuscitation continues without asking the
family or relatives about the patient’s previous wishes on whether or not to resuscitate. Most often, these
558 Nursing Ethics 22(5)

patients die after large-scale interventions from a technical and pharmacological point of view regardless
the will of the patient or the relatives.
In the above-mentioned situations, the nurses describe an ethical conflict in relation to the physician
when it comes to performing their role as the patient’s advocate. The nurses express discomfort, with feel-
ings of moral distress, suffering, anger and helplessness.

Acknowledgements
We are grateful to all those participants interviewed.

Conflict of interest
The authors declare that there is no conflict of interest.

Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit
sectors.

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