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Nursing Ethics 2008 15 ( 4) 2008 SAGE Publications 10.1177/0969733008090519

NURSES WORKPLACE DISTRESS

AND ETHICAL DILEMMAS INTANZANIAN 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 ques-tion guide was used and the study focused on the answers that 29 registered nursessupplied. The theme, Tanzanian registered nurses invisible and visible expressionsabout existential conditions in care, emerged from several subthemes as: suffering from(1) workplace distress; (2) ethical dilemmas; (3) trying to maintaining good quality nurs-ing care; (4) lack of respect, appreciation and influence; and (5) a heavy workload thatdid not prevent registered nurses from struggling for better care for their patients. Theanalysis shows that, on a daily basis, nurses find themselves working on the edge oflife and death, while they have few opportunities for doing anything about this situ-ation. Nurses need professional guidance to gain insight and be able to reflect on theirsituations, so that they do not become overloaded with ethical dilemmas and workplacedistress.

IntroductionNursing is a stressful occupation1 and Garner2 identified job stress as the strongestpredictor of job satisfaction. An unsatisfactory work/personal life balance, an organ-ization not focused on patient needs, outdated medical equipment, and insufficientdevelopment opportunities have led to rising levels of job stress for nurses.3 In add-ition, there is evidence to show that work overload and inadequate staffing, inter-personal relationships, and dealing with hospital administration are other majorsources of stress.4 As Kitua et al.5 argue, the lack of trained staff, equipment, drugsand funds, and inadequate health care facilities, are among the top 10 health

service problems in Tanzania. These can cause ethical dilemmas for health carepersonnel. Yet, people have the right to expect competent, high quality, ethical andpersonalized 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: [email protected]

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Workplace distress and ethical dilemmas 479

Nursing Ethics 2008 15 (4)

nursing have so far been mainly related to the aggressiveness of treatment,6 andhave not yet been systematically studied in Tanzania. A dilemma can be definedas a difficult problem seemingly incapable of a satisfactory solution, or a situ-ation involving a choice between equally unsatisfactory alternatives.7 Studiesabout nurses job stress and ethical dilemmas have been conducted in developedcountries, 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 perceptionsof their work experiences are questioned in these countries, and that factors thatare considered stressful and affect their job performance are minimized. In the lightof this, the aim of the present study was to describe Tanzanian nurses meaningof and experiences with ethical dilemmas and workplace distress in differentcare settings.

Method

Participants

Twenty-nine Tanzanian registered nurses participated in the study. They were allqualified, had practiced nursing for more than two years, and were from varioushealth care settings. At the time of the study, these nurses had taken part in a con-tinuing education program.

Data collection

Data were collected from written responses to open questions (as Tang et al.8) inorder to gain insight into Tanzanian nurses views of ethical dilemmas and work-place distress, and lead to an understanding of the participants lived experiences.

The role of the researcher when reading the informants written answers was toreflect on the question of how the nurses expressed their meaning about ethicaldilemmas and workplace distress.

The phenomenological-hermeneutic approach

The text was analyzed using a phenomenological-hermeneutic approach inspiredby the philosophy of Ricoeur,9 which has been used previously.1012 According toRicoeur,9 lived experiences will always remain private and therefore it is notpossible to express them to another person, although some meaning of experiencescan emerge. The method implies that the researcher interprets the written answersin order to understand the informants experiences. The analysis is carried out inthree steps, from nave reading to a structural analysis, and to interpretation of thewhole. The nave reading and the results of the structural analysis are read in rela-tion to researchers pre-understanding, and the questions that arise during theanalytic stage are interpreted in the light of the text.13 The first and third authorspre-understanding stems from their background as Swedish registered nurses andresearchers; the second authors background is as a Tanzanian registered nurse andteacher.

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480 E Hggstrm et al.


AnalysisA process of open and critical reading and interpretation of the material was carriedout throughout the structural analysis phase. The content of the meaning-bearingunits, condensations, subthemes, and theme was read repeatedly, until the final sub-themes and theme were established. The second author, who first made an inde-pendent 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 thenames and the description should be. Finally, all three authors reached a consensus(Table 1).

Ethical considerationThe study was given approval by the Head of the Faculty of Nursing, KilimanjaroChristian Medical College, Tanzania. Relevant information about the research wasgiven verbally to the participants by the first researcher. Participation in the studywas voluntary and the study followed ethical principles. It was stressed that the

information would be kept confidential and that the participants had the right tochoose whether or not to answer the questions.

Findings

Nave understanding

The Tanzanian nurses, who worked in several different departments, seemed toexperience their work as mostly filled with difficulties. These included: feeling asthough they fell short in their work because they had too many duties; the lack ofequipment or defective equipment; and not having enough training or knowledge.Other difficulties that played a role in their daily work included lack of acknow-ledgement and understanding from their supervisors and even feelings of not beingvalued or of being disparaged by their supervisors and doctors. The nurses tried tomake the best of the situation because they protect their patients, but every day theyare forced to handle difficult decisions and ethical dilemmas because of the pres-sures of their work situation. This can negatively affect nurses self-confidence andself-reliance, and sometimes these difficulties even seemed to affect the nurses exist-ential thoughts about themselves and their patients.

Structural analysis

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

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Table

1

Exampleoftheanalysis

Meaning-bearing

Condensed

meaning-

Subtheme

Theme

unit

bearingunit

Onepatientdiedd

uetoa

Onepatientsufferedbecause

Sufferingfrom

Tanzanianregister

ednurses

shortageofequip

ment.

ofhavingtroublebreathing

workplac

edistress

invisibleandvisibleexpressions

Hecametomyu

nitwith

andthend

iedduetothe

aboutexistentialconditions

breathingdifficulty.

lackofequ

ipment.

incaresituation

s

Heneededimme

diate

oxygentherapyb

ut

duetotheshorta

geof

oxygen,

thepatie

nthad

tostruggleuntilhedied.

Whenthedoctorincharge

Thenurseis

invited/requested

Sufferingfrom

Tanzanianregister

ednurses

directedmetogivefirst

togiverichpatientspriority

ethicaldilemmas

invisibleandvisibleexpressions

prioritycaretoa

person

becausetheycanpaythe

aboutexistentialconditions

whoisrichandtoleave

doctorsom

eextramoney

incaresituation

s

thosepeoplewhodonot

haveanymoney

togivehim

tothankhim

for

thehealthcare.

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The main theme (Tanzanian registered nurses invisible and visible expressions about

existential conditions in care situations) arose from the authors interpretation of thesubthemes (Table 2). The nurses expressed that ethical dilemmas and workplace dis-tress arise because they have to work on a daily basis in conditions that have to dowith the very existence of life. For example, the patients chances of survival andwhether they obtain good care or die depend on what resources are available in a givensituation. The nurses said they worry about their own health and their own livesbecause protective gear and equipment are often missing and, therefore, every day theyrisk serious infections. That the nurses sometimes have to prioritize rich over poorpatients relates to both patients and nurses because of the fear of losing their jobs andnot daring to protest about this. The meaning of ethical dilemmas and workplace dis-tress 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 theirviews to management and doctors. At other times it is invisible, such as their ownthoughts about ethical dilemmas and workplace distress, which they do not share withothers, 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 toseveral different shortages in their workplace that result in inadequate care forpatients and in feelings of guilt on the part of the nurses. The shortage of well-educated staff, especially nurses, and the insufficient number of nurses on duty dur-ing 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 registerednurses, although Im exhausted.

This could sometimes result in a nurse forgetting to give a patient a prescribedmedicine and thus cause the nurses to feel guilty for not carrying out their job per-fectly, despite that being their intention.

Table 2 Subthemes and theme of the meaning of ethical dilemmas and work-

place distress

Subthemes Theme

Suffering from workplace distress Tanzanian registered nurses invisible andSuffering from ethical dilemmas visible expressions about existentialSuffering from trying to maintain conditions in care situations.

good nursing qualitySuffering from the lack of

respect, appreciation, and influenceSuffering from a heavy workload

does not prevent registerednurses from struggling for bettercare for their patients

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I felt so bad when I remembered that I had forgotten to give the patient important dia-betic 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 atthe same time they always had to prioritize who would receive care first, becauseof the lack of resources. Several of the nurses stories also reveal how the shortageof equipment could result in fateful consequences. One patient died as a nurse

watched and there was nothing she could do because the few available ventilatorswere all being used.

One patient died due to a shortage of equipment. He came to my unit with difficultywith breathing. He needed immediate oxygen therapy but due to the shortage ofoxygen, the patient had to struggle until he died.

Education and continuing education were not available to these nurses, whichcaused feelings of discomfort and disinclination because they could not keep up withmedical developments and use new scientific knowledge and proven methods tocare for their patients.

In the nurses daily work, they could give patients only the care that it was pos-sible to give, even if this often meant a risk to their own health. Working with infec-tious patients without access to adequate safety equipment was experienced as verytrying and the nurses always felt threatened by the possibility of becoming infectedwith 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 theirdaily work of protecting patients integrity and confidentiality. There was a lack of

space where nurses could meet patients privately. Examinations, nursing care andconversations all took place in front of other patients. Secrecy was also unnecessarilybroken by staff talking to unauthorized people and even to one another when itwas not needed, especially about HIV diagnoses. The problem of HIV positivepatients being stigmatized occurred frequently, according to the participantnurses. This ethical dilemma could have its origin in the lack of collaboration andknowledge about HIV positive patients because of which patients rights were oftenviolated.

No confidentiality, especially for patients with HIV infections. After being diagnosed, somehealth 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 carerights. This often causes staff to be careless about informing patients about occur-rences of incorrect treatment and leads to nurses experiencing ethical dilemmas thatthey do not do anything about.

Patients must know their ethical rights. That is why most of the staff dont follow theethical 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 andencouraged by doctors to prioritize rich patients before poor ones. Some patientsalso offered the nurses payment to obtain faster and quicker health care. There werealso bureaucratic difficulties in obtaining money from the government for needypatients so they could pay and receive adequate treatment in time. All the dilemmasconcerning 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 pos-sibilities of fighting against them.

When the doctor in charge directed me to give first priority care to a person who is richand 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 givepatients the care they needed in time, when they had to choose who should receivecare first and, in acute situations, when a quick decision had to be made. Accordingto 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 toanother 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 fewtrained staff members for the number of patients and the lack of resources, they alsotalked about how they try to maintain good care for patients. These nurses are proudof 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 mypatients recover. I enjoy my work.

The quality of the care provided was described by the nurses as not bad. If thenecessary equipment was available, the nurses thought that the quality of patient carewould 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 theneeds of our patients.

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



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to a worsening of quality. The reasons for this could be that the number of patientsin relation to the number of staff is too high and the lack of resources makes stafflose their motivation for work, resulting in morale being negatively affected. Thenurses sometimes think that the quality of the care provided is affected negativelybecause of the high workload and they said they can feel overwhelmed by the situ-ation. Medical staff also experience frustration because of inadequate knowledgeabout the basic elements of patient care.

Everybody tries very hard to fulfill his or her duty despite the great number of patientsin a ward or patients allocated to one nurse. I think, if possible, [the number of] patientsper nurse should be reduced, otherwise we end up with poor quality care.

Care quality is also frequently affected by most of the patients inadequate know-ledge about their illnesses and by some of them having trouble speaking the officiallanguage, Swahili.

Suffering from lack of respect, appreciation and influence

The nurses stated they experience inadequate respect for their work and their self-esteem, 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 haveproblems. Often, the supervisors do not care if nurses talk about or want to be lis-tened to regarding something that is difficult in their work, such as the staff short-age, too many patients, insufficient resources, the need for training, and the need formore qualified staff.

I think we lack the confidence or, I can say, the self-esteem to air out our views whenthere 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 agood job. If something has gone wrong, such as a patient complaining about his orher care, the nurse gets the blame rather than there being a thorough investigationinto what has happened. Management was also described as favoring certain nurses,who then obtain advantages that others do not, such as receiving training or beingpromoted. Some nurses said they felt discriminated against because they are treateddifferently, 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 knowmuch about medicine and health care. The doctors think that the nurses should doonly what they are told and should not question doctors prescriptions or put for-ward 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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better work conditions and better status by officially calling attention to their situ-ation in meetings and at conferences. The nurses stated that they have many goodstrengths among them, and they want to continue to work in Tanzania and improvecare for patients.

Some registered nurses who have the possibility often those without children moveabroad 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 theytry 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 raisestandards. The difficulties with this are that everyone works long shifts and thatthere is no money to pay for overtime. Despite this, they put in a lot of effort so thatstaff training can be improved. They also try to undergo training themselves, just asthey 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 updatemy knowledge to get to my desired level in patient care.

The nurses also talked about how they try to encourage and convince staffmembers to think positively about their work. They say that the situation is verydifficult and serious, but that they have to work for change and try to concentrateon positive changes and situations each day. In this way, the nurses work towardsthe 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.

DiscussionThe aim of this study was to describe a group of Tanzanian nurses experiences withethical dilemmas and workplace distress in different care settings. The results plainlyshow that these nurses find themselves in a very difficult work situation, as indicatedby the overarching theme of: Tanzanian registered nurses invisible and visible expres-sions about existential conditions in care situations. The nurses expressed that ethicaldilemmas and workplace distress come from having to work on a daily basis in con-

ditions that have to do with the very existence of life, which can affect nurses both atwork and in their private lives. This can be compared with the Swedish situation withregard to municipal health care for elderly people, where staff have been shown to beaffected both at work and privately by the ethical dilemmas they experience in want-ing to give the care required, but are unable to do so because of lack of time and theythen place the blame for this on themselves.12

The Tanzanian nurses felt inadequate at work because there are too few staff, thestaff 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 numberof nurses. Hertting et al.14 and Olofsson et al.15 showed in their studies that healthcare personnel are negatively affected by having too many patients and work dutiesin proportion to the number of staff, which can lead to the staff becoming stressedand thus to a worsening of the quality of the health care provided. A similar situ-ation of lack of educated staff and of resources has been described regarding nurseswork in China.8 However, the Tanzanian nurses, more so than the Chinese nurses,

emphasized the lack of protective gear and equipment, describing their belief thattheir lives are in danger because of this combined with the serious infectiousdiseases they come into contact with on a daily basis.8 The Tanzanian nurses mean-ing of and experiences with ethical dilemmas and workplace distress also have todo with the lack of appreciation from both their supervisors and doctors. They talkedabout unfair treatment and being blamed for situations that went wrong withouthaving the chance to defend themselves. They also describe how doctors look downon them, disparage them or do not value their knowledge, and do not listen to themwhen they try to give suggestions for patients care. As in other reports, this studyshows that the participant Tanzanian nurses do not receive sufficient informationabout 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 notdifferentiate between how Chinese and western nurses describe their opportunitiesfor being part of and being able to affect patients health care.8,19 Chinese nurses havedescribed how they feel like doctors assistants,8 which can be compared with theTanzanian nurses, who frequently described how doctors view them as ignorant andthink they should just follow doctors orders. A big problem for the Tanzanian nursesis that sometimes doctors encourage them to prioritize rich patients before needyones because doctors accept bribes from those who can pay to receive better healthcare. This phenomenon has not been described in other studies and therefore maypossibly be considered unique to Tanzania.19 This causes difficult ethical dilemmasbecause 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 careprofessionals views on how financial factors and evaluations affect patients healthcare when financial factors take precedence over humanistic ones.20 Despite theirdifficult work situation, the participant Tanzanian nurses tried to do their bestfor their patients, usually saying that they like their patients and that they even liketheir work.

In the present study, the in-depth analysis of the Tanzanian nurses work situationshowed that, on a daily basis, they find themselves working on the edge of life anddeath, while they have few opportunities for doing anything about this situation. Asnurses 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 currentwork situation. This is an ethical dilemma in which these Tanzanian nurses want tolive up to the demands placed on them that is, to give patients good care butthis is often impossible because of the circumstances. This results in feelings of frus-tration and low levels of self-confidence and self-reliance. Buber23 describes the meet-ing of a person being cared for and the person caring for him or her; for theseTanzanian nurses, this would be a mutual and vulnerable exchange in which they

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would be acknowledged in their work roles. However, this acknowledgement can-not occur when the opportunities for giving good care are reduced, and this resultsin their low self-esteem and their experience of often finding themselves in situationsof ethical dilemmas and existential difficulties.24,25 These difficulties can be both vis-ible and invisible, as expressed in this studys overarching theme: Tanzanianregistered nurses invisible and visible expressions about existential conditions incare situations.

Methodological considerationsA phenomenological-hermeneutic method was used for this study. Generally, narra-tive interviews would be used, but in this study the researchers chose to use a ques-tion guide with open questions. This was so that the Tanzanian nurses could answerthe questions in peace and quiet, without having to think about speaking Englishwell. According to Ricoeur,26 the starting point for analysis is the written text. Whenthe text is analyzed, it is the researchers interpretation that is emphasized. In thisstudy, 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 rela-tion to the deeper meaning of the Tanzanian nurses ethical dilemmas and workplacedistress. The nurses wrote long, comprehensive responses to the open questions, andsimilarities in what became this studys deeper interpretation were found in all thetexts, which strengthens the studys trustworthiness.27 The small number of partici-pants in this study (n29) does not allow the results to be generalized, althoughthey could increase understanding in supervisors and nurses who work in healthcare in Tanzania, and even for others in similar situations.26

ConclusionsNo authors of previous studies have reported on the issue of ethical dilemmas andworkplace distress experienced by Tanzanian nurses in health care situations. Thepresent study therefore contributes new knowledge to this field. The findings showedthat Tanzanian nurses are in a difficult work situation and that they need help andsupport in the form of being seen and acknowledged at work. This requires moreeducated staff, more support to be given by supervisors who are present in the worksituation and who acknowledge nurses, and a more positive opinion from doctors.Other factors that need to be improved are better equipment for patients and betterprotective gear and equipment for nurses. Another conclusion is that these nursesneed 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 nothave to overload themselves with ethical dilemmas and workplace distress.28

Acknowledgements

The authors wish to express their gratitude to the Faculty of Nursing, KilimanjaroChristian 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 Tanzanianregistered nurses who participated in this study. For linguistic revision, our thanksgo 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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