Meanings of troubled conscience and how to deal with it: expressions of Persian‐speaking enrolled nurses in Sweden

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A feature of the healthcare system in Sweden, particularly in the care of older people in residential facilities including nursing homes, is its cultural diversity in terms of having considerable numbers of both caregivers and care recipients with an immigrant background. More than 12% (n = 234 889) of the population in Sweden who are aged more than 65 years are of foreign origin 1.
In Sweden, 1.82% of the total population (n = 173 135; 2012) live with dementia. Many of these individuals move to residential care facilities when they reach the advanced stages of dementia and die there 2. In residential care for people with dementia, the Registered Nurses (RNs) are responsible for medicine administration 3 and the care is mainly provided by enrolled nurses (ENs) 4 who mostly have 3 years' vocational high school education. Approximately 19% (n = 33 665) of ENs and nursing assistants (NAs) in Sweden are foreign born 5.
Researchers in Sweden have studied several ethnic and immigrant older people, for instance, those with Finnish 6, Iranian 8 and Turkish 14 backgrounds, among others 13. Their studies showed that there are difficulties in engaging with immigrant family members of people with dementia to recruit them as participants in research studies 13. The researchers emphasised the importance of being aware of the meaning that an illness experience has for some patients with an immigrant background 14, as well as large differences 10 between immigrants' experiences of dementia 8. Further, differences in caring for people with dementia in Sweden 9 compared to the immigrants' own home country 10, and the importance of employing bilingual nursing staff in residential care facilities for people with dementia 6, have been highlighted.
Nursing older people encompasses involvement with ethical issues and decisions 16. Caregivers who feel they cannot provide care of high quality, for example, experience stress of conscience 20 which is a type of stress caused by a troubled conscience. (Areas related to) Conflicts of conscience may relate to the dissonance between person and society, person and person, and also within an individual, and these dissonances may lead to a troubled conscience 22. Feelings of failure to live up to expectations from others, for example, from patients and also from co‐workers and supervisors, contribute to stress of conscience, which is often measured by employing a questionnaire (stress of conscience questionnaire [SCQ]) 21. Juthberg et al. 24 have shown that one‐third of the caregivers in a residential care setting perceived their conscience as being too strict and that one in five caregivers indicated that they needed to deaden their conscience in order to keep working in health care.
There are varying descriptions of what constitutes a troubled conscience, each of which depend on a granted understanding of the concept of conscience in combination with a specific perspective of, for example, religion 25, philosophy 26, sociology 27, psychology 28 and nursing 29. A conscience can be labelled as troubled 30 or untroubled 31. A troubled conscience could be described as ‘a conscience that hurts’ 32. Nursing staff in a municipal residential older care facility in Sweden narrated meanings of a troubled conscience as ‘being trapped in powerlessness’ and ‘being inadequate’ 33. According to another Swedish study 34, situations generating a troubled conscience include being caught between different demands, being torn away from residents to tend to other ‘must do's’, feeling unable to relieve suffering, and being part of providing care that feels wrong.
According to Juthberg et al. 17, a perceived lack of time for performing care activities was the most common reason for stress of conscience for RNs.
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