Abstract
Objective
To reveal the challenges faced by nurses providing palliative care to hospitalized patients and to determine their levels of stress of conscience while delivering palliative care.
Method
In this cross-sectional and descriptive study, a total of 143 nurses providing palliative care in the intensive care and oncology units of a university hospital were included in the study. The Nurses Descriptive Characteristics Form, Palliative Care Difficulties Scale and Stress of Conscience Questionnaire were used to collect the data. In the analysis of the data, arithmetic mean, Cronbach’s alpha, Independent Samples t-test, Analysis of Variance test, Mann Whitney test, Kruskal-Wallis test, Spearman’s Correlation were used.
Results
The mean age of the participants was 31.26 ± 6.88 years. While 25.9% of them defined the concept of conscience as “compassion”, 21.0% defined it as “empathy”. The mean scores they obtained from the Stress of Conscience Questionnaire and the Palliative Care Difficulties Scale were 86.8 ± 48.7 and 42.6 ± 8.3, respectively. There was no statistically significant relationship between the scores they obtained from the overall the Palliative Care Difficulties Scale and the Stress of Conscience Questionnaire (p > 0.05). The relationship between the participants’ the Palliative Care Difficulties Scale scores and the variables such as sex, and the department they work in was statistically significant (p ≤ 0.05).
Conclusion
The results of this study revealed that nurses providing palliative care should be supported, and that being female and having a postgraduate education positively affected conscience. It may be recommended to focus on ethical issues related to palliative care in undergraduate and graduate education.
Relevance to clinical practice
Nurses providing palliative care in areas such as intensive care and oncology encounter numerous ethical issues and experience moral distress while maintaining effective communication with their patients and ensuring continuity of care. Supporting these nurses through national and international policies will positively impact the quality of care.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12904-026-02063-7.
Keywords: Palliative care, Stress of conscience, Care difficulty, Ethical issues, Nurse
Introduction
Conscience is not only perceived as a signal warning us that our personal and professional values, beliefs, ethics or standards may be threatened by the problems and conditions encountered [1] but also supports nursing care in line with ethical values [2]. Since nursing whose members are in close contact with the patient tries to improve the quality of life, concepts such as conscience, stress of conscience, and conscientious objection may be regarded as contradictory concepts with professional nursing [3, 4]. However, these concepts should be included in professional ethical value issues since the field of interest of nursing is human.
Conscience stress has been defined by Glasberg et al. as the stress caused by a troubled conscience that arises when a person does not follow the voice of their conscience or when their personal conscience conflicts with themselves, others, or society [5]. In patient care, conscience stress arises when nurses are unable to act in accordance with their conscience, when they encounter morally stressful situations [6] and constraints that may affect their conscience, or when they are forced to act contrary to their conscience [3, 7], or when they are unable to resolve the ethical dilemma they experience [8]. Situations that cause conscience stress in long-term care include interpersonal relationships, difficulties in determining priorities, compromising on good care, being forced to provide care that they believe is wrong, working conditions in healthcare affecting the duration of care, not having enough time to meet the patient’s needs, and their private lives affecting their work [6, 8, 9]. Conscience stress is related to nurses’ awareness that they cannot meet their own ethical standards while working with patients and is particularly affected by the problems they experience in providing good care and protecting patients from harm [8]. Conscience, as the process by which thoughts and actions are judged, is seen as a factor that helps nurses maintain their ethical integrity and provide appropriate care to patients [10]. Therefore, conscience forms the basis of ethical nursing care [11].
Approaches that prevent or alleviate pain and suffering through early diagnosis, correct evaluation and treatment of physical, psychosocial or spiritual pain and other problems are addressed within the framework of palliative care [12]. Palliative care which is an important part of nursing care is a process in which conscience plays an effective role in making the best decision on behalf of the patient [13]. Nurses may have trouble in the care process of patients receiving palliative care. Especially in palliative care, it is very difficult to bring up and talk about processes related to the end of life and the dying process. In studies conducted with nurses providing palliative care, having difficulty understanding patients’ reactions to the dying process, having communication problems, giving bad news, and informing patients’ relatives inadequately were among the difficulties they had in providing care [14, 15]. These problems are experienced more frequently by patients staying in intensive care units and especially by patients with chronic progressive cancer. In this process, nurses may sometimes suffer from stress of conscience while they make decisions to do what is best for the patient [14].
In a study, it was stated that stress of conscience was common among health professionals, varies according to demographic factors, and is related to burnout, job stress, clinical atmosphere, moral sensitivity, and quality of care [6]. Stress of conscience is an important element since it increases the sensitivity of nurses in the care process. The number of studies in the literature in which nurses’ palliative care difficulties and stress of conscience are investigated together is limited. The aim of this study is to determine the conscience stress levels of nurses working in palliative care and intensive care units, to examine the relationship between conscience stress and palliative care perception, and to evaluate whether conscience stress differs according to sociodemographic and occupational characteristics. In this direction, it is also aimed to determine the perceptions of nurses regarding the concepts of conscience and palliative care.
Research questions
What is the level of stress of conscience of nurses working in palliative care and intensive care units?
Is there a significant relationship between nurses' conscience stress and their perception of palliative care?
Does the level of stress of conscience of nurses (such as gender, unit of study, education level, duration of working in the department) differ according to sociodemographic and professional variables?
Nurses' perception of palliative care (gender, unit worked, working time in the department etc.)?
What are the perceptions of nurses about the concepts of conscience and palliative care?
Methods
Design and methods
In the present cross-sectional and descriptive study, data were collected from 143 nurses who met the inclusion criteria between January 2023 and June 2023. The study was conducted at a university hospital located in the Mediterranean region of Turkey.
The study population included all nurses providing palliative care in the intensive care and oncology units, although no unit is officially listed under the name “palliative care.” Nurses working in these units who were informed about the study, voluntarily agreed to participate, and completed the data collection forms in full were included in the study.
Nurses who did not complete the questionnaire, withdrew from the study, or were on annual leave during the data collection period were excluded. In palliative care, nurses manage patients’ symptoms, provide psychosocial support, educate patients and families, coordinate multidisciplinary care, and enhance quality of life while respecting ethical principles and maintaining accurate documentation.
Data were collected via face-to-face interviews using a structured questionnaire and validated measurement scales. Participants completed the questionnaire under the supervision of the researcher, with an average completion time of approximately 15 min.
Setting and sample
The population of the study consisted of 143 nurses who worked in one of the intensive care and oncology clinics of aforementioned hospital and were not on leave or on sick leave.
The sample size was calculated using Epi Info™ StatCalc, assuming a 99.99% confidence level and a Type I error rate of 5%, which indicated a minimum required sample of 131 nurses [16]. All eligible nurses in the target population agreed to participate in the study; therefore, the final sample consisted of 143 nurses.
Data collection tools and methods
Nurses descriptive characteristics form
The form developed by the researchers in line with the literature consists of 11 items questioning the participants’ sociodemographic characteristics such as sex, age, etc., and their characteristics related to palliative care and stress of conscience [17, 18].
Palliative care difficulties scale (PCDS)
The PCDS was developed by Nakazawa et al. (2010) [19]. Akdeniz Kudubeş et al. (2019) [20] conducted the validity and reliability study of the Turkish version of the PCDS. The PCDS consists of 15 items whose responses are rated on a five-point Likert type scale ranging from 1 (Never) to 5 (Always) corresponding to the degree of the difficulties of palliative care. Minimum and maximum possible scores that can be obtained from the overall PCDS are 15 and 75, respectively. The scale consists of the following five sub-dimensions: communication in multidisciplinary teams, communication with the patient and family, expert support, reduction in symptoms and communication coordination. The higher the score obtained from the PCDS is the higher the level of difficulties experienced by palliative care providers is. The Cronbach’s α coefficient of the PCDS was 0.81 in Akdeniz Kudubeş et al.’s study (2019) and 0.84 in the present study [20].
Stress of conscience questionnaire (SCQ)
The SCQ was developed by Glasberg et al. in 2006 [5]. The validity and reliability study of the Turkish version the SCQ was conducted by Aksoy et al., (2020) [18]. The SCQ has nine items whose responses are rated on a six-point Likert type scale. There are two categories A and B for each item in the scale. The aim in category A is to assess how frequently the person is faced with the stated situation. The frequency is rated on a six-point Likert type scale ranging from 0 (Never) and 5 (Every day). In category B, the level of stress of conscience caused by this situation is assessed. The level of stress is rated on a six-point Likert type scale ranging from 0 (No, it does not trouble my conscience at all) to 5 (Yes, it troubles my conscience greatly). The score for each item is calculated by multiplying the scores obtained from categories A and B. The sum of the scores calculated for each item gives the score for the overall SCQ. The maximum score that can be obtained from the SCQ is 225. The higher the score is the higher the level of stress of conscience is. The Cronbach‘s α coefficient of the scale was 0.74 in Aksoy et al.’s study (2020) [18], and 0.88 in the present study.
The researchers administered the data collection forms to collect data from the participating nurses who volunteered to participate in the study and worked in the intensive care and oncology clinic of an X university hospital. It took them approximately 12 min to fill in the forms.
Data analysis
Statistical analyses were performed using the SPSS (Statistical Package for the Social Sciences) (IBM SPSS Statistics 27). Frequency and descriptive statistics were used to interpret the results. The normality of continuous variables was assessed using the Kolmogorov–Smirnov test and visual inspection of histograms. In accordance with parametric methods, the “Independent Sample-t” test (t-table value) was used to compare the measurement values of two independent groups, whereas the “ANOVA” test (F-table value) was used to compare the measurement values of three or more independent groups. For the pairwise comparison of the variables with significant differences in case there were three or more groups, the Tukey test was performed by taking into account the homogeneity of the variances.
Variables that did not meet the assumption of normal distribution were analyzed using non-parametric methods. In accordance with non-parametric methods, the “Mann-Whitney U” test (Z-table value) was used to compare the measurement values of two independent groups, and the “Kruskal-Wallis H” test (χ2-table value) method was used to compare the measurement values of three or more independent groups. For the pairwise comparisons of variables with significant differences in case there were three or more groups, Bonferroni correction was applied. Spearman’s correlation coefficient was used to determine the relationship between measurement values that did not have a normal distribution.
Relationships between non-normally distributed variables were examined using Spearman’s rank correlation coefficient. A p-value of ≤ 0.05 was considered statistically significant.
Ethical and research approvals
In line with the standards for national ethics rules, ethics committee approval was obtained from the ethics committee of a university (Decision Number: KAEK XXX, Decision Date: November 9, 2022). Permission to conduct the study was obtained from the hospital management where the study was to be conducted. Before data was collected, a written informed consent was obtained from the participants after the purpose of the research in accordance with the Helsinki Declaration was explained. The participants were also informed about the fact that their participation was voluntary, and their answers would be kept confidential and evaluated only as scientific data.
Results
The mean age of the participants was 31.26 ± 6.88 years. Of them, 79.7% (n = 114) were women, 67.8% (n = 97) worked in intensive care units, 64.3% (n = 92) had a bachelor’s degree, 53.8% (n = 77) had no training in palliative care, 76.2% (n = 109) worked 40 h a week, and 58% (n = 83) did not consider resigning from the profession. Their mean lengths of service in the department and in the profession were 1.32 ± 0.47 and 9.08 ± 7.06 years, respectively.
While the mean score the participants obtained from the SCQ was 86.8 ± 48.7, the mean score they obtained from the PCDS was 42.6 ± 8.3. The relationship between the scores they obtained from the overall PCDS and SCQ was not statistically significant (p > 0.05).
Table 1 presents participants’ first associations with the concepts of conscience and palliative care: Participants most frequently associated the concept of conscience with compassion (25.9%) and empathy (21.0). Palliative care was most commonly associated with effective or holistic care (28.7%), followed by death (14.7%) and end-of-life care (14.0%) (Table 1).
Table 1.
Participants’ first associations with conscience and palliative care concepts
| Concept | Response Category | n | % |
|---|---|---|---|
| Conscience | Compassion | 37 | 25.9 |
| Empathy | 30 | 21.0 | |
| Moral value | 11 | 7.7 | |
| Feeling of pity | 11 | 7.7 | |
| Inner voice | 8 | 5.6 | |
| Peace of mind | 7 | 4.9 | |
| Doing the right thing | 6 | 4.2 | |
| Sensitivity | 7 | 4.9 | |
| Goodwill | 5 | 3.5 | |
| Other* | 21 | 14.6 | |
| Palliative Care | Effective / holistic care | 41 | 28.7 |
| Death | 21 | 14.7 | |
| End-of-life care | 20 | 14.0 | |
| Elderly care | 17 | 11.9 | |
| Well-being | 8 | 5.6 | |
| Other** | 34 | 25.1 |
*Other (Conscience): mother, nurse, self, humanity, elderly, child
**Other (Palliative Care): chronic disease and pain, comfortable death, etc.
The mean SCQ score was 86.8 ± 48.7, and the mean PCDS score was 42.6 ± 8.3. No statistically significant relationship was found between the total SCQ and PCDS scores (p > 0.05).
Table 2. Comparison of the mean scores the participants obtained from the Palliative Care Difficulties and Stress of Conscience Questionnaire in terms of some of their characteristics: In the comparison of the data without normal distribution, the “Mann-Whitney U” test (Z-table value) was used to compare two independent groups, and the “Kruskal-Wallis H” test (χ2-table value) was used to compare three or more independent groups. There were statistically significant differences between the participants’ scores for the PCDS in terms of the “sex” (Z=-2.946; p = 0.003), “department they work in” (t = 2.195; p = 0.030) and “length of service in the department” (χ2 = 8.362; p = 0.039) variables. The results of Bonferroni corrected pairwise comparisons made to determine from which group the significant difference stemmed demonstrated that the difference stemmed from those who worked in the department for ≤ 1 year and those who worked for 2–5, 6–9 or ≥ 10 years. No statistically significant difference was determined between the participants’ scores for the SCQ and the PCDS in terms of the variables such as age group and length of service in the profession (Table 2; p > 0.05).
Table 2.
Comparison of the mean scores the participants obtained from the palliative care difficulties and stress of conscience questionnaire in terms of some of their characteristics
| Variable (N=143) | n | PCDS | SCQ | |||
|---|---|---|---|---|---|---|
| x̄ ± SD* | Median [IQR] | x̄ ± SD* | Median [IQR] | |||
| Age groups (years) | ||||||
| ≤25 | 30 | 42.17±8.54 | 44.5 [8.0] | 99.53±57.66 | 100.0 [73.5] | |
| 26-30 | 51 | 41.37±9.27 | 42.0 [11.0] | 81.82±47.47 | 72.0 [74.0] | |
| 31-35 | 30 | 45.43±8.01 | 45.5 [12.5] | 91.97±42.73 | 97.0 [44.8] | |
| >35 | 32 | 42.38±6.12 | 43.0 [9.0] | 77.84±46.04 | 89.0 [68.8] | |
| Statistical analysis** | χ2=3.530 | F=1.342 | ||||
| Possibility | p=0.317 | p=0.263 | ||||
| Sex | ||||||
| Women | 114 | 43.78±7.35 | 45.0 [10.0] | 90.16±48.56 | 90.5 [61.5] | |
| Men | 29 | 38.04±10.16 | 40.0 [11.0] | 73.48±47.93 | 84.0 [87.5] | |
| Statistical analysis | Z=-2.946 | Z=-1.303 | ||||
| Possibility | p=0.003 | p=0.193 | ||||
| Unit they work in | ||||||
| Intensive care | 97 | 43.65±7.49 | 45.0 [10.0] | 87.29±51.02 | 91.0 [72.0] | |
| Oncology clinic | 46 | 40.43±9.49 | 42.0 [11.0] | 85.69±44.02 | 86.0 [56.0] | |
| Statistical analysis | t=2.195 | t=0.182 | ||||
| Possibility | p=0.030 | p=0.856 | ||||
| Length of service in the department (years) | ||||||
| ≤1 (1) | 11 | 34.73±9.78 | 39.0 [17.0] | 100.63±53.67 | 115.0 [99.0] | |
| 2-5 (2) | 66 | 43.19±6.67 | 43.5 [8.5] | 94.25±50.47 | 95.5 [54.3] | |
| 6-9 (3) | 25 | 42.00±11.27 | 46.0 [11.0] | 71.12±40.41 | 70.0 [54.0] | |
| ≥10 (4) | 41 | 44.17±7.14 | 45.0 [11.0] | 80.56±47.47 | 88.0 [62.5] | |
| Statistical analysis | χ2=8.362 | χ2=5.666 | ||||
| Possibility | p=0.039 | p=0.129 | ||||
| Difference | [1-2.3.4] | |||||
| Length of service in the profession (years) | ||||||
| ≤1 (1) | 10 | 38.00±10.25 | 42.5 [11.0] | 83.00±67.62 | 109.5 [136.0] | |
| 2-5 (2) | 43 | 41.81±7.32 | 41.0 [10.0] | 104.96±55.24 | 102.0 [88.0] | |
| 6-9 (3) | 36 | 43.77±10.20 | 46.0 [9.8] | 82.22±35.79 | 94.5 [67.3] | |
| ≥10 (4) | 54 | 43.33±7.00 | 44.0 [10.0] | 76.24±43.96 | 81.0 [56.5] | |
| Statistical analysis | χ2=6.374 | χ2=6.485 | ||||
| Possibility | p=0.095 | p=0.090 | ||||
n: Number of participants, x̄ ± SD =Arithmetic mean±Standard Deviation; Independent Sample-t test =t; One-way ANOVA=F; Kruskal–WallisH test= χ²; Mann–Whitney U test,=Z
Table 3. Comparison of the mean scores the participants obtained from the overall Palliative Care Difficulties and Stress of Conscience Questionnaire in terms of some of their characteristics: There were statistically significant differences between the participants’ scores for the SCQ in terms of the “Educational Status” variable (F = 5.018; p = 0.002). The results of Tukey pairwise comparisons made by taking into account the homogeneity of the variances to determine from which group the significant difference stemmed revealed that there was a significant difference between those who were high school and associate degree graduates, and those who were postgraduate degree graduates. No statistically significant differences were determined between the participants’ scores for the SCQ and the PCDS in terms of their descriptive characteristics such as receiving palliative care training, caregiving approach, weekly working hours, and considering resignation (Table 3;p > 0.05).
Table 3.
Comparison of the mean scores the participants obtained from the overall palliative care difficulties and stress of conscience questionnaire in terms of some of their characteristics
| Variable (N=143) | n | PCDS | SCQ | ||
|---|---|---|---|---|---|
| x̄±SD* | Median [IQR] | x̄±SD* | Median[IQR] | ||
| Educational status | |||||
| High school (1) | 23 | 44.00±9.28 | 47.0 [10.0] | 73.30±29.60 | 87.0 [48.0] |
| Associate degree (2) | 15 | 41.13±8.36 | 44.0 [7.0] | 60.80±39.15 | 70.0 [63.0] |
| Undergraduate (3) | 92 | 42.29±8.39 | 42.0 [10.8] | 89.09±51.78 | 93.0 [69.8] |
| Postgraduate (4) | 13 | 44.15±5.51 | 44.0 [11.5] | 124.15±40.36 | 115.0 [63.5] |
| Statistical analysis | χ2=3.223 | F=5.018 | |||
| Possibility | p=0.359 | p=0.002 | |||
| Difference | [1.2-4] | ||||
| Receiving training on palliative care | |||||
| Yes | 66 | 42.23±8.40 | 88.24±42.81 | 93.0 [50.0] | |
| No | 77 | 42.94±8.23 | 85.52±53.54 | 88.0 [75.0] | |
| Statistical analysis | Z=-0.298 | t=0.338 | |||
| Possibility | p=0.766 | p=0.736 | |||
| Caregiving approach | |||||
| Patient centered | 62 | 42.45±9.45 | 44.5 [11.3] | 77.58±44.94 | 80.0 [71.0] |
| Patient and work centered | 79 | 42.63±7.39 | 43.0 [8.0] | 94.94±50.72 | 95.0 [63.0] |
| Statistical analysis | Z=-0.414 | Z=-1.780 | |||
| Possibility | p=0.679 | p=0.075 | |||
| Weekly working time | |||||
| 40 hours | 109 | 43.49±7.19 | 44.0 [9.0] | 90.51±49.67 | 91.0 [68.5] |
| 45 hours | 34 | 39.79±10.77 | 43.0 [12.0] | 74.79±44.18 | 86.0 [65.0] |
| Statistical analysis | Z=-1.408 | Z=-1.470 | |||
| Possibility | p=0.159 | p=0.141 | |||
| Planning to resign | |||||
| Yes | 28 | 40.61±7.95 | 40.0 [9.5] | 100.86±40.12 | 108.0 [48.5] |
| No | 83 | 42.87±7.75 | 44.0 [10.0] | 82.43±46.22 | 87.0 [65.0] |
| Undecided | 32 | 43.72±9.78 | 45.0 [11.0] | 85.72±59.95 | 78.5 [83.5] |
| Statistical analysis | χ2=3.382 | F=1.517 | |||
| Possibility | p=0.184 | p=0.223 | |||
n Number of participants, x̄ ± SD : Arithmetic mean±Standard Deviation; Independent Sample-t test =t; One-way ANOVA=F; Kruskal–WallisH test= χ²; Mann–Whitney U test,=Z
Table 4 displays the three most highly endorsed and the three least endorsed statements from the PCDS and the Stress of Conscience Questionnaire (Table 4).
Table 4.
Three statements with the highest agreement and three statements with the lowest agreement in the PCDS and SCQ
| Scales (N=143) | n | Mean | SD |
|---|---|---|---|
| Palliative Care Difficulties Scale | |||
| Three statements with the highest agreement | |||
| It is difficult to communicate about symptom reduction in multi-professional teams. | 75 | 3.68 | 1.09 |
| There is a lack of information on reducing cancer pain. | 42 | 3.15 | 1.09 |
| Sharing information between hospitals and home care providers is difficult. | 33 | 2.97 | 1.03 |
| Three statements with the lowest agreement | |||
| It is difficult to get help from experts (specialists) in reducing symptoms. | 92 | 2.36 | 0.81 |
| There is no specialist that I can consult about reducing symptoms. | 72 | 2.48 | 0.97 |
| It is difficult to respond when a patient expresses his or her anxiety. | 24 | 2.63 | 0.99 |
| Stress of Conscience Questionnaire (Part A) | |||
| Three statements with the highest agreement | |||
| Does your job in healthcare leave you without the energy to devote yourself to your family as much as you would like? | 33 | 3.55 | 1.52 |
| How often do you experience time constraints to provide the care the patient needs? | 29 | 3.18 | 1.70 |
| Do you ever have to deal with inconsistent requests in your work? | 48 | 2.76 | 1.52 |
| Three statements with the lowest agreement | |||
| Have you ever distanced yourself from patients or relatives who need help or support? | 19 | 1.40 | 1.61 |
| Have you ever witnessed patients being insulted and/or being hurt? | 22 | 1.45 | 1.63 |
| Do you ever lower your expectations for good caregiving? | 29 | 2.08 | 1.72 |
| Stress of Conscience Questionnaire (Part B) | |||
| Three statements with the highest agreement Does this give you any moral distress? | |||
| Does your job in healthcare leave you without the energy to devote yourself to your family as much as you would like? | 31 | 4.08 | 1.35 |
| How often do you experience time constraints to provide the care the patient needs? | 26 | 3.78 | 1.65 |
| Do you ever have to deal with inconsistent requests in your work? | 32 | 3.76 | 1.59 |
| Three statements with the lowest agreement Does this give you any moral distress? | |||
| Have you ever distanced yourself from patients or relatives who need help or support? | 15 | 2.30 | 2.02 |
| Have you ever witnessed patients being insulted and/or being hurt? | 13 | 2.61 | 2.16 |
| Do you ever lower your expectations for good caregiving? | 16 | 2.66 | 2.08 |
n Number of participants, M Mean, SD Standard deviation, min Minimum, max Maximum
Discussion
In the present study, nurses who cared for patients receiving palliative care defined the concept of conscience as “compassion”, “empathy”, “moral value”, “sense of pity” and “inner voice”, whereas they defined the concept of palliative care as " effective or holistic care”, “death”, “end-of life care”, “elderly care” and “well-being”. In the literature, nurses defined conscience as a “compass” that would guide their decision-making processes [10, 17], and they stated that they perceived conscience as an authority, a warning signal, responsibility, and sensitivity [21]. Cleary & Lees (2019) define conscience as a “source of sensitivity” that includes acting according to professional intuition, knowing limitations, and responding to vulnerability [1]. In their study Jodaki et al. (2021) state that conscience directs a person’s feelings and thoughts in complex situations [10], helps distinguish right from wrong, and motivates nurses to provide morally correct nursing care. In a study conducted with nurses working in a palliative care unit, they define palliative care as “communication”, “provision of pain-free, trouble-free care and training to patients in the last period of their lives”, “enabling them to have a comfortable and convenient terminal period”, and “supportive care“ [22]. As in the present study and in other studies, conscience is defined in different ways, and it is considered as a concept which is a positive stimulus in making the best decision on behalf of the patient based on professional ethical values. In the definition of palliative care, the main emphasis is on care provided in the terminal period, preservation of the highest quality of life, prevention of pain and suffering. In this process, it is also possible to say that conscience is an important element that directs nurses to be sensitive in the decision-making process.
In the context of palliative care challenges, the problems prioritized by the participating nurses in the present study were as follows: communication-related difficulties in teamwork, lack of information on reducing pain in cancer patients, and difficulties in sharing information between the hospital and the home care system. On the other hand, the participants gave lower scores to statements about receiving expert help and counseling to reduce symptoms during care and having difficulty responding to the patient expressing anxiety. In a study conducted with nurses caring for a dying patient in Turkey, the nurses stated that it was difficult not being able to relieve the patient’s pain [23]. Demir (2016) state that the palliative care process begins for both the patient and the patient’s relatives from the moment a life-threatening disease is diagnosed, and it continues in line with the needs [14]. It is emphasized that the nurse-patient relationship plays a key role in maintaining and improving the quality of care, protecting professional ethical values, and making the best decision for the benefit of the patient [24]. According to nurses providing palliative care, ethical problems were as follows: difficulties arising from the personnel shortage, lack of adequate medical-administrative support, patient/relative or colleague collaboration problems, and difficulties in meeting the various needs of different patient groups [24].
Studies conducted with nurses working in intensive care and palliative care have indicated that inadequate hospital infrastructure and environment, particularly due to staff shortages, cause difficulties in care and lead to substandard care [22, 25]. Other studies in the literature on this subject have stated that conflicting instructions given by nurses, physicians, or other responsible nurses [26], lack of communication between healthcare professionals and families, stress, and lack of procedures for end-of-life care cause difficulties in palliative care [25]. These results show that palliative care is multidimensional and that problems arise from team members, limited resources, patients, and their relatives during the process. Minimizing these difficulties is seen to positively affect nurse performance and improve the quality of care, and is therefore important for palliative care units.
In the present study, issues leading to the highest degree of stress of conscience and conscientious distress induced by stress of conscience in the participants were as follows: running out of all their energy while performing their profession and not having the energy to spare time for their own families, not having enough time to give patients the care they needed, and having to deal with requests outside of work. On the other hand, issues that caused the least amount of conscientious distress and stress of conscience in the participants were as follows: not alienating themselves from patients and their relatives during the care process, not witnessing any patient being insulted, and not lowering their own expectations of providing good care. It is stated that in situations where dilemmas occur in nursing care, conscience can direct nurses to provide quality care based on ethical values [3, 8, 10, 27, 28]. In several studies, nurses emphasized that conscience is one of the elements that established balance between personal belief and professional obligations, and that institutional, local, and national policies to prevent stress of conscience underlying ethical concerns were important [17, 23]. In several other studies, nurses experienced stress of conscience when they felt that they could not provide quality care which they believed that it was their duty [8, 23, 29]. These results are consistent with those obtained in the present study.
In this study, female nurses working in intensive care units who had served in the units for two years or longer obtained significantly higher scores on the PCDS. A similar result was found in a study conducted with nurses providing palliative care [30]. One study found that palliative care practices and palliative care challenges were not related to variables such as gender, length of service in the clinic, and professional experience [31]. It can be said that the difference observed in this study may have been due to regional differences experienced by the participants and the cultural roles of women.
In the present study, of the participants, only those with postgraduate education obtained significant mean scores from the SCQ. In the study conducted in Turkey, contrary to our study, variables such as age, professional experience, choosing the profession willingly and staff shortage in the service affected the nurses’ SCQ scores significantly [29]. In another study, it was determined that a significant relationship was determined between conscientious intelligence and education level, and that those who had the undergraduate degree obtained higher mean scores [31]. Based on the results of the study, it can be said that the increase in stress of conscience in those with postgraduate education is related with the fact that the participants’ sensitivity levels increase as their education levels increase.
There were no statistically significant differences between the scores the participants obtained from the SCQ and the PCDS in terms of the variables such as receiving training on palliative care, caregiving approach, weekly working hours, considering resignation. In Van Diepen et al.’s study, as the number of patients cared for decreased, so did the level of stress of conscience [32]. In Özden & Parlar Kılıç’s study, professional experience and the length of service in the clinic had a significant positive effect on palliative care practices [31]. In the present study, of the participating nurses, those who did not receive training on palliative care obtained significantly higher scores from the Palliative Care Difficulties Scale, and variables such as educational status, length of service in the clinic, length of service in the profession, and receiving training on palliative care were not related to conscientious intelligence [31]. The difference between the results of studies probably stemmed from the difference between the participants’ workloads.
As the aim in health care practices is to achieve what is good and right for people who need medical treatment and nursing care, such practices involve a moral endeavor. In the present study, while the mean score obtained from the SCQ was at the moderate level (86.8 ± 48.7), the mean score obtained from the PCDS was above the average (42.6 ± 8.3). There was no statistically significant relationship between the mean scores obtained from the two scales. In a study, the maximum score that could be obtained from the PCDS was 160, and the mean score the participating nurses obtained from the scale was 56.51 ± 7.81 [31]. In another study, the mean score the participants obtained from the SCQ was approximately the same as that obtained in the present study [29]. It is known that palliative care nurses experience ethical dilemmas while trying to make good decisions for the patient’s benefit, and that this negatively affects them emotionally. Studies show that healthcare workers who perceive conscience as a warning signal to avoid harming others experience more intense conscience stress [3]; intensive care nurses have stated that high workload, time management issues, existing rules, and management’s demand that they focus on documentation lead to conscience conflict [33]. It can be said that palliative care challenges and moral distress are factors that affect care.
To assist nurses with conscientious issues, helping them gain ethical reasoning, critical self-awareness, and effective interpersonal communication skills through theoretical and practical training [1], and their being supported and understood by their leaders, in other words, creating a professional environment where they can share their feelings and thoughts is of great importance [22]. Jodaki et al., (2022) emphasized that it is important to prepare guidelines to reduce the factors likely to cause intensive care nurses to experience conflict of conscience, to follow them in terms of stress of conscience and burnout, to support them by providing psychological counseling, to organize rotations within the institution, and to provide stress management training [33]. In the light of the results of the present study and the literature, it is possible to say that nurses experience stress of conscience during the palliative care process, and that their awareness should be increased further.
Limitation
This cross-sectional, single-center study included only nurses providing palliative care in intensive care and oncology units, which may limit the generalizability of the findings. In addition, the use of self-reported data may have introduced response and recall bias. Finally, the descriptive design of the study limits the ability to draw causal inferences.
Implications and recommendations for practice
This study showed that nurses working in intensive care units and oncology units where palliative care is provided experience notable levels of stress of conscience. Although no direct relationship was found between stress of conscience and overall perceptions of palliative care, stress levels varied according to sociodemographic and professional variables such as gender, education level, and years of experience. Nurses’ perceptions of palliative care also differed depending on the unit worked and duration of employment.
Nurses most commonly associated conscience with compassion and empathy, and palliative care with holistic and effective care, highlighting the ethical dimension of palliative practice. These findings indicate the need for institutional and policy-level support to reduce stress of conscience among nurses, particularly in palliative care settings. In addition, strengthening ethics education related to conscience and palliative care in undergraduate and graduate nursing programs may help nurses manage ethical dilemmas more effectively and improve the quality of care.
Supplementary Information
Acknowledgements
I would like to thank the nurses who participated in the study at the Çukurova University intensive care unit.
Authors' contributions
***Meryem Türkan IŞIK*** ***1*** ***:*** Study conception and design, Data analysis and interpretation, Drafting of the article, Critical revision of the article.***Rana CAN ÖZDEMİR*** ***2*** ***:*** Study conception and design, Data analysis and interpretation, Critical revision of the article.***Çiler ÇOKAN DÖNMEZ*** ***3*** ***:*** Study conception and design, Data collection and interpretation, Critical revision of the article.
Data availability
The datasets generated and/or analysed during the current study are not publicly available due privacy of personal information and ethical issues but are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
In line with the standards for national ethics rules, ethics committee approval was obtained from the ethics committee of Akdeniz University (Decision Number: KAEK 674, Decision Date: November 9, 2022). Permission to conduct the study was obtained from the hospital management where the study was to be conducted. Before data was collected, a written informed consent was obtained from the participants after the purpose of the research in accordance with the Helsinki Declaration was explained. The participants were also informed about the fact that their participation was voluntary, and their answers would be kept confidential and evaluated only as scientific data.
Consent for publication
Participants/nurses gave written consent for the publication of personal information contained in this study.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and/or analysed during the current study are not publicly available due privacy of personal information and ethical issues but are available from the corresponding author on reasonable request.