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Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
https://doi.org/10.1186/s12912-020-00438-6
RESEARCH ARTICLE
Open Access
Emotions and feelings in critical and
emergency caring situations: a qualitative
study
María F. Jiménez-Herrera1* , Mireia Llauradó-Serra2, Sagrario Acebedo-Urdiales1, Leticia Bazo-Hernández1,
Isabel Font-Jiménez1 and Christer Axelsson3
Abstract
Background: Moral emotions are a key element of our human morals. Emotions play an important role in the
caring process. Decision-making and assessment in emergency situations are complex and they frequently result in
different emotions and feelings among health-care professionals.
Methods: The study had qualitative deductive design based on content analysis. Individual interviews and focus
groups were conducted with sixteen participants.
Results: The emerging category “emotions and feelings in caring” has been analysed according to Haidt,
considering that moral emotions include the subcategories of “Condemning emotions”, “Self-conscious emotions”,
“Suffering emotions” and “Praising emotions”. Within these subcategories, we found that the feelings that nurses
experienced when ethical conflicts arose in emergency situations were related to caring and decisions associated
with it, even when they had experienced situations in which they believed they could have helped the patient
differently, but the conditions at the time did not permit it and they felt that the ethical conflicts in clinical practice
created a large degree of anxiety and moral stress. The nurses felt that caring, as seen from a nursing perspective,
has a sensitive dimension that goes beyond the patient’s own healing and, when this dimension is in conflict with
the environment, it has a dehumanising effect. Positive feelings and satisfaction are created when nurses feel that
care has met its objectives and that there has been an appropriate response to the needs.
Conclusions: Moral emotions can help nurses to recognise situations that allow them to promote changes in the
care of patients in extreme situations. They can also be the starting point for personal and professional growth and
an evolution towards person-centred care.
Keywords: Moral emotions, Emergency care, Critical care
Background
Nurses in the current health-care environment are confronted by complex situations arising from the conflicting values and beliefs of other health-care professionals.
In these circumstances, moral emotions arise from
* Correspondence: maria.jimenez@urv.cat
1
Nursing Department, Universitat Rovira i Virgili (URV), Av/ Catalunya, 35
43002 Tarragona, Spain
Full list of author information is available at the end of the article
different feelings related to not being able to ensure the
best interests of the patient and relatives. Understanding
why and how moral emotions arise may help nurses to
develop the caring process and make it visible to all
health-care professionals. Our theory is that, if nurses
are aware of their moral emotions, this will help them to
cope in different situations and improve nursing
practice.
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Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
Definition of emotion
Emotions play an important role in the caring process,
but there is still a shortage of articles relating nursing to
emotions. Learning more about emotions is a key
component in the nursing profession. The concept of
emotion has multiple definitions. The lack of a definition
is a constant source of numerous misunderstandings
and a series of mostly fruitless debates between different
disciplines [1]. In this report, we use the definition formulated by Scherer, Schorr and Johnstone in which they
define emotions as an episode of interrelated, synchronised changes in all or some of the five organismic
subsystems when responding to an external or internal
event of concern. These five components are the cognitive system (what you think), the subjective process
(how you interpret), the action tendencies (e.g. running
away), the physiological changes (e.g. changes in blood
pressure or size of pupil) and the motor expression (e.g.
body language) [2, 3].
How do emotions arise?
To give a brief interpretation, emotions arise from the
body’s responses to external or internal stimuli. The response is dependent on your life experience, e.g. cultural
factors, upbringing, education and so on [4, 5]. Feelings
are a part or an expression of/from these stimuli. A feeling can trigger an emotion or be the response to one.
This means that the terms “emotion” and “feelings” are
used to illustrate separate actions. Emotions and feelings
are often used interchangeably in everyday language.
Moral emotions
Moral emotions, instincts, and intuitions form the moral
brain, which allows people to make ethical decisions, according to Haidt [6]. These emotions are the catalyst for
promoting positive actions and avoiding negative ones
[7, 8]. People carry out actions and behaviours that are
built on the information they obtain from previous experiences, both positive and negative. Moral emotions are
the response to situations, sometimes of well-being, and
sometimes of anguish or suffering of people [8]. The author classifies moral emotions into four families: condemning emotions, self-conscious emotions, praising
emotions, and suffering emotions [9].
The difference between moral emotions and basic
emotions is that the basic emotions come from ideas,
the imagination or the perception of immediate selfrealisation such as sadness, happiness, anger, disgust or
joy [10]. The moral emotions are linked to the interests
and/or the well-being of all people, as well as individuals.
Furthermore, the moral emotions are evoked in circumstances that extend beyond the immediate sphere of self,
such as empathy and compassion and, finally, the emotions relating to praising others, such as gratitude.
Page 2 of 10
Finally, the main contribution to the caring ethic practices [11–14] is that it enriches our understanding of
moral reasoning and decision-making. However, caring
ethic practices include topics that have been ignored in
rational ethical theories, such as the moral emotions.
Moral emotions in nursing care
Nursing care is an interpersonal experience and those
providing care witness emotional signals that can be described as physical, psychological or existential [15].
These signals are considered to be a moral experience to
perform moral work [16]. However, the motivation to
act for another individual may involve an element of
personal gain and it is plausible that nurses find caring
for others emotionally rewarding. A study of 56 nurses
found that nurses had more empathy than other healthcare professionals. The author suggested that moral
emotions and empathy may be a natural part of the profession, important for nursing roles and the caring
process [17]. In nurses’ experiences of care, they also
found experiences of emotional guilt, anger and frustration in relation to moral conflicts. Many of these situations were patient related and associated with acts of
physical care that cross physical, social and personal
boundaries [18].
Visible emotions in care situations
The interaction between the nursing professionals and
other participants in the process of care is understood as
an exchange of emotions, actions and experiences. In
acute situations, it is necessary to focus and act quickly
to continue the caring process. The arousal of feelings is
secondary to the situation. It is impossible to avoid feelings, because feelings are a mental experience of body
states, which arise as the brain interprets emotions.
Regardless of why emotions occur, whether or not
they are appropriate or respond to certain cognitive patterns, our goal is to approach the emotions of professionals in acute care practice, emotions that arise from
the interaction between the nursing professionals and
other participants in the process of care. Our theory is
that, if nurses are aware of their emotions, this will help
them to cope in different situations. If a nurse learns to
act intelligently as a result of emotions, this will improve
nursing practice [19].
The overall aim of this study is to make nurses aware
of moral emotions that could arise during their everyday
work while taking care of patients and relatives in emergency situations.
Aim
To analyse how emergency nurses describe the moral
emotions arising from emergency care situations.
Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
Method
Organisation
The study took place in Catalonia, Spain, at a university
hospital and on the advanced life support (ALS) ambulance in the same town that has 131,255 inhabitants. In
the present study, the aim was to select a group of
nurses with experience in ALS ambulance care and
emergency department (ED) care.
Sample
The sample of participants in the study corresponds to
that presented in the first part of the study where the
category ethical issues was analysed [20].
Sixteen nurses aged 27–47 years agreed to participate
in the study. The nurses worked at the ED, at the ALS
or both units. The mean time worked was 16.86 years.
The description of the socio-demographic characteristics as well as years of experience and type of participation in the study are reflected in Table 1. All the nurses
participating in the study were invited to participate in
interviews and in the FG; 14 nurses took part in the interviews and 12 in the FG.
Data collection: interview
Data were gathered using interviews. The role as interviewer was that of an encouraging, non-normative neutral facilitator so that the participants could explain
themselves as fully as possible [21]. Each interview took
around 90 min, was recorded on an audio file and transcribed verbatim. Transcriptions have been made after
each interview to provide a clear recollection of the
Page 3 of 10
interview; to increase the reliability, parts of the interviews have been listened to many times. To avoid interference during data collection, this was done outside the
care units.
A semi-structured interview guide was created by the
authors (Table 2) to facilitate these interviews with specifics topics on the relevant experiences of the participants. In order to stimulate reflections on the research
phenomenon, follow-up questions were posed such as:
Could you describe the situation? Do you remember the
situation in a positive or negative way? How is the atmosphere in the service? Do you have any strategies for
managing your feelings?
Data collection: focus group (FG)
The FG Each took around 120 min, was recorded on an
audio file and transcribed verbatim. For the development, a FG guide was created (Table 3) according to
help the expert in group dynamics, with some open
questions from different themes arising during the interviews. In order to stimulate reflections on the research
phenomenon, follow-up questions were posed such as:
How is the care organised at the emergency/ED service?
What kind of feelings and emotions do you have in
emergency situations? How do the professionals react
when faced by situations involving suffering and pain?
The FG technique allowed us to deepen in aspects
related to their emotions and feelings in very diverse
situations and that could be contrasted among the
participants. The members of the focus group share
Table 1 Characteristics of informants
AGE RANGE
25–30
31–35
36–40
41–45
46–50
CODE
YEAR OF EXPERIENCE
FIELD
PARTICIPATION
PARTICIPATION
ENF12
6
AMBULANCE/ED
INTERVIEW
***
ENF16
7
AMBULANCE/ED
***
FG
ENF1
8
AMBULANCE/ED
INTERVIEW
***
ENF2
14
AMBULANCE/ED
INTERVIEW
FG
ENF8
16
AMBULANCE/ED
INTERVIEW
***
ENF10
17
AMBULANCE/ED
INTERVIEW
FG
ENF13
12
ED
INTERVIEW
***
ENF5
16
AMBULANCE/ED
INTERVIEW
FG
ENF6
15
AMBULANCE/ED
INTERVIEW
FG
ENF15
15
AMBULANCE
***
FG
ENF3
20
ED
INTERVIEW
FG
ENF7
22
ED
INTERVIEW
FG
ENF9
21
ED
INTERVIEW
FG
ENF11
23
ED
INTERVIEW
FG
ENF14
19
ED
INTERVIEW
FG
ENF4
22
ED
INTERVIEW
FG
*** non participate at he Interview or FG
Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
Table 2 Guide notes for the interview
Guide notes for the interview
Guide questions
Exploratory goals
Since when are you a doctor/nurse? Age, gender, formation, years of
professional experience, work
Where did you study nursing/
fields.
medicine?
Page 4 of 10
Table 3 Guide notes for the direction and development of the
Focal Group
Guide notes for the direction and development of the Focal Group
1 Informed consent and autonomy:
Who takes the decisions about people’s health in the emergency
service?
In which fields have you worked?
Can the person take decisions in the emergency service?
Since when are you in the
emergency department?
Whenever not accepted what is offered, what happens?
What has meant for you to be a
nurse/doctor?
Developed activities
What does it mean for you to take
care? And to cure?
How understands the illness/
healing and caring processes
How are they dealt with?
How are perceived the persons
demanding assistance
Types of relationships built
between the professionals and
with who demands the services
Satisfaction/Dissatisfaction of
people
Description of situations they have Description of the context and
lived and remember in a positive or situations
negative way
What does taking care feels like?
Feelings of different nature in
front of lived situations
Would you change anything?
Value/exchange value
Do you have any strategies for
managing your feelings?
Ethics Conflicts
Do patients take part of the
decisions?
Caring strategies
What professionals take part when
taking ethic decisions?
Communication
How is the atmosphere in the
service?
2 Pain and suffering: Is there pain and suffering in the emergency
service?
Power relations
Work conditions
Relationships with the other
members
Conflicts
Personal and professional
satisfaction/ Moral distress
How does the professional react in front of these situations?
3 Power relations, moral distress, people’s care management in
the service.
How is it managed the caring in the emergency service?
How the professional does connects with the patients in emergency
situations?
Feelings and emotions around caring in emergency situations
How is the activity managed in the emergency service?
And in emergencies outside the hospital, is there any difference?
4 Abuse of therapeutic effort and CPR (cardiopulmonary
resuscitation)
In extreme and terminal situations, until when is prolonged the
assistance?
Up to which point is the technique invading the human being?
What is the role played by the family members?
5 Information:
People demand more information. What happens in matter of
urgency situations?
And in emergencies? Enough information.
6 Death, advance directives
How is dying in casualty? And in emergency services? Professional’s
suffering-acceptance.
7 Casualty service. Professional’s perception of:
Why do people come to casualty?
Going to casualty as an alternative of treatment, why? When?…
Team work
Status/Role
Rules, strategies, tactics
experiences with one another, they are able to highlight individual viewpoints, empower the participants
and validate their experiences and be regarded as an
expert [22, 23].
Data analysis
A qualitative approach was chosen and the collected
data were analysed deductively, according to content
analysis [24]. The primary aim of this is to describe the
phenomenon in a conceptual form from different levels
of content: themes and main ideas of the text as primary
content and context information as latent content. In
the process of analysis, three basic forms are used: summarisation, explication and structuring.
We carried out the analysis of the material from focus
groups and interviews in several steps. After the verbatim transcription of the interviews, all personal identifiers were removed or replaced and a letter and a
number were attributed to each participant. Deductive
category application works with previously formulated,
theoretically derived aspects of analysis, connecting them
with the text.
The analysis explored the data to identify patterns in
the way nursing expresses the emotions based on the
classification by Haidt [9] to report the experiences and
Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
the reality of the participants based on a data-driven and
systematic procedure which permits searching across
data sets to identify repeated patterns of meaning [25].
Within this framework, systematic stages were
followed and simultaneous analysis was undertaken. (a)
The transcriptions were read and the data were re-read
several times to obtain a sense of the overall data; (b)
the text was divided into meaning units; (c) in the abstraction process, the meaning units were coded and the
codes were compared, contrasted and sorted into preliminary subcategories; (d) by going back and forth
among the preliminary subcategories, the codes and the
text subcategories were identified; (e) the final step in
the analysis was to use the categories according with
Haidt’s moral emotions families which describes the entire results and connects all the subcategories. The analysis was carried out by the main author (M.J.) and the
analysis was evaluated by means of discussions between
all the authors during the analysis process and by emphasizing the emotions underlying the care experiences.
Ethical considerations
Clinic and ambulance managers were informed about
the study, which they subsequently approved. This study
was explained to the nurses in a group and they were
told that (a) participation was voluntary and (b) they
could leave the study at any time. Each individual gave
her written informed consent to participate in the study.
The nurses participated on a voluntary basis and were
reassured of data confidentiality. All the participants
were verbal informed of the voluntary nature of the research and were told that their participation (or nonparticipation) would not affect their health services and
after they provided written consent format to participate
prior to data collection.
Fig. 1 Moral emotions
Page 5 of 10
To maximise confidentiality, no names or other identifiers were recorded in the audio file or on the interview
transcripts. The interviewers introduced the study in
person and asked the participants whether they had any
questions. The importance of maintaining the confidentiality of other participants, by not sharing their views
outside the focus group setting, was stressed at the start
of the interview.
Data from the transcripts of interviews and focus
groups were collected according to the Law 15/1999 on
the Protection of Personal Data. The research project
was piloted and approved by the clinical committee at
the reference hospital, according to Spanish law for nonbiomedical studies.
Results
We present one main category, “emotions and feelings
in caring” relate with moral emotions. This category was
strongly linked to the caring process. The subcategories
were condemning emotions, self-conscious emotions,
praising emotions and suffering emotions. Figure 1
shows the category with the different subcategories [20].
Condemning emotions
These emotions are related to the negative feelings
nurses experience when they have to take part in ethical
situations related to the care given by other professionals. In this subcategory, we could include feelings
such as disgust, anger or contempt, which sometimes
arise in extreme situations when the treatment that is
given is not appropriate or when practices could be described as inhuman or violent, e.g. compulsory. The
nurses expressed these feelings from emotions when
their viewpoint was not taken into account in the
decision-making process. They were not allowed to be
Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
Page 6 of 10
involved in the planning of good care and felt that the
medical treatment displaces nursing care and does not
include it as a part of the patient’s treatment process.
When nurses talk about the treatment of pain, they see
it as an ethical matter and, when it is not addressed adequately, this generates a feeling of anger in them.
The emergency nurses highlighted the fact that the
lack of teamwork between professionals harms the patients and provokes these emotions. The lack of teamwork also impairs the individual effort and the
relationship between all the participants in the healthcare team.
“ … that’s why I get annoyed. Because, despite having many tools, we still have to keep asking whether
or not to give the patient a painkiller. This triggers
one’s temper, to say: ‘come on, this person is suffering’, e.g. vascular patients who have had pain for
many hours, it’s very easy to give them something.”
GF:R4 [6]
“(…) the professional relationships must be based on
consensus within the team, because, if there is no
dialogue, nothing works in the optimal way. At the
hospital, the team doesn’t talk, there is no dialogue,
they don’t work well together… this often results in
many ‘loose ends’ and a lack of understanding about
what happened… each member plays his part and it
goes as it goes (…) this makes me feel ashamed about
not being able to solve it (…).” ENF2 [2]
The nurses also felt anger in situations when the assessment did not involve both patient and family and when
actions that were unnecessary for the patient were performed. The feeling was that some professionals only
focus on an organ or a set of organs, while some view
the person as a whole, taking account of other aspects
that are an important part of life.
“( … ) in my experience, the patient’s life is prolonged
as much as the doctor wants and maybe the patient
has written not to resuscitate him or her in the event
of cardiac arrest. I don’t understand it, you are telling me there’s nothing we can do and we are filling
them up with tubes, serums, catheters, drugs… if
there is no chance of waking up, why are you
prolonging unnecessary agony? The patient can’t feel
a thing, but what about the family members?
“You should see how they suffer, how they cry… it
tears your heart out. Even if you ask the doctor ‘what
are you doing?’, if he thinks that they have to keep
on, they keep on… Finally, the patient will die, but
adorned like a Christmas tree, not as a human being. Yesterday, a woman died on my watch about
whom, for more than a week, we had only heard
“there’s nothing we can do”, but she wasn’t short of
anything, noradrenaline, tubes, catheters, serums…
There comes a time when you get tired of speaking
and not being listened to.” GF: R10 [19]
Self-conscious emotions
Self-conscious emotions provoke negative feelings like
shame, guilt or embarrassment. Nurses report that, when
they had experienced a situation in which they believed
they could have helped the patient differently, but the
conditions at the time did not permit it, they felt guilty
about having taken part in the process. Nurses feel vulnerable in these situations where they cannot act.
Nurses feel shame and guilt because they see clearly that
there is no teamwork and this affects the caring process.
Praising emotions
Within this subcategory, we include the feelings that
could be defined as satisfactory and positive; they arise
when nurses feel that care has met its objectives and that
there has been an appropriate response to needs. Nurses
highlight the fact that these positive feelings gratify and
motivate them to continue advancing and developing a
more complete and satisfying nursing practice for both
patients and professionals.
“(…) helping people makes me feel fulfilled, you are
next to them in very serious and critical situations
and we are behind the care given at these difficult
moments. We help them with their problems; help
them to keep on living. Sometimes we find that we
are powerless because we can’t do anything to help
them… that’s the two sides of the same coin (…).”
Enf2 [7]
Another participant highlights the need to do the right
things to experience this kind of feeling, because it produces a significant degree of personal satisfaction as a
professional.
“(…) sometimes the situations fluctuate tremendously, we can go from one extreme to the other:
from maximum satisfaction to the utmost helplessness. I am determined never to fail, I must be
one hundred per cent. Feelings like this help me
to act. It requires an extra effort because time is
precious and perhaps we have to resolve situations that may endanger a patient’s life. At the
same time, they help me to develop as a human
being ( … ).” Enf8 [4, 5]
Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
When nurses participate in this decision-making
process, they feel good in spite of the difficulties that
may arise in the situations they must face.
“(…) in emergencies, things happen quickly and we
often don’t have time to stop and think, I feel that I
am part of the situation I am in ( … ).” Enf8 [8]
Suffering emotions
The nurses felt that care, as seen from a nursing perspective, has a sensitive dimension that goes beyond the
patient’s own healing and, when this is in conflict, it
dehumanises the assistance. Nurses believe that the caring perspective must consider a special moral sensitivity
in order to respond to the needs of the patient.
The informants state that distress coming from a morally negative emotion is the main source of moral distress. Moral distress is made up of emotions that appear
when, for various reasons, it is impossible to follow the
right course.
Nurses suggest that there are external constraints that
cause these situations, such as the institutional structure
and its bureaucratisation, as well as the strict hierarchy
that exists among professionals in hospital. This situation has its origins in a power structure, more or less
open, and, in other cases, invisible influences in the
nursing/caring process.
According to one of the nurses:
“(…) no, you are not taken into account for anything.
If you were, sometimes things would have gone differently, at least from my own experience. You can
argue, discuss, share opinions, it’s all useless. According to them, they are the captain and a sailor has to
obey. Sometimes you are certain that the patient is
going to die, but we still purify the blood and give
antibiotics. We treat them with the most advanced
and expensive therapeutic facilities Do you have any
idea how much a haemofilter costs? Do you know
how much unnecessary spending is generated? Do
you know how much suffering we cause people? It
is hard to live with this, I get angry, we talk
about it with our colleagues… you can’t do anything and feel helpless. However, when I see these
atrocities, I tell them: ‘don’t ever do that to me’.
The most distressing thing is when the patient’s
family comes in and you see that agony. It breaks
my heart and I realise that I am part of this…”
Enf10 [9]
The informants sometimes felt that they were used to
reaffirm the treatment and they did not have enough
power to be the patient’s advocate. The following informant tells us about her experiences.
Page 7 of 10
“(…) no, they don’t ask you. They very seldom do,
but, if they do, it’s because they are searching for reaffirmation of their opinion and to be told that they
are doing the right thing.” Enf3 [8]
“(…) No, no, we don’t take an active part. Everything
is under their control, everything is medicalised.
Until the day arrives when nurses are on the same
level as doctors and their work is valued by the
medics, it will be very difficult for nurses to take part
in the decision-making process when confronted by
ethical issues (…).” Enf 4 [9]
The nurses say that they want to participate in the processes, bringing their experience and knowledge, but
they feel that their opinions not are taken into account.
“(…) Nowadays, nurses are in the clinical sessions,
but their opinion is not taken into account; this
should change gradually, the nurse knows the patients and defends them from aggressions that might
occur even from health professionals. They do not
usually take account of the information we provide,
Physicians make decisions one hundred per cent of
the time based on subjective criteria, which appear
to be the only valid ones (…).” Enf 6 [8]
Discussion
The overall impression from the findings from this extensive material was that nurses were preoccupied with
existential thoughts about positive and negative moral
emotions derived from caring relationships, such as
emotions.
Moral emotions are linked to welfare, to do good and
avoid doing bad. The present results found that the
nurses who participated in the study indicated aspects
that confirmed the existence of moral emotions that influence the caring process, sometimes positively and
sometimes negatively.
Nurses are likely to feel condemning emotions like
anger when assessing a situation relating to the patient
and his/her family which goes against their view of the
way things should be done and when they believe that
action that is unnecessary for the patient could be
avoided.
To do good from a nursing perspective is to take account of dimensions including the relationship between
the patient and family. This perspective often differs
from other sciences which focus on the biomedical perspective [11].
From the perspective of condemning emotions, anger
is linked to the interests of others rather than to themselves. From this perspective, anger is a motivational
force that energises the individual to defend situations in
Jiménez-Herrera et al. BMC Nursing
(2020) 19:60
order to provide better care and avoid damage to the patient [10].
We found that this type of negative feeling constantly
recurred in the emergency practices and was a topic of
consensus among the interviewed nurses. Nurses need
to develop their role in the team and other professionals
need to include them in the ethical decisions. Other
studies have shown the need for a nursing perspective in
similar situations [26, 27].
Emotional responses from nurses in these situations
vary a great deal. The informants state that a morally
negative emotion is the main source of moral distress.
Moral distress appears when, for various reasons, it is
impossible to follow best practice and is independent of
context-given specific preconditions: when nurses are
morally sensitive to the patients’ vulnerability, when
nurses experience external factors preventing them from
doing what is best for the patient and when nurses feel
that they have no control over the specific situation [28].
This gives the professionals a sense of helplessness,
frustration, anger, resignation and guilt. What is worse,
it can provoke states of depression associated with the
loss of professional integrity, feelings relate with selfconsciousness moral feelings.
Nurses has suffering feelings from the most common
sources are excessively aggressive treatments, the misuse
of resources, a lack of communication between professionals and patients, treatment goals that are poorly defined and poorly understood by all the members of the
care team, a lack of respect for the will of the patient
and the loss of continuity of care due to a lack of collaboration and consensus; both excessive interventions and
the therapeutic neglect of patients could result from the
latter actions [20].
The nurses suggested that there are external constraints that cause these situations, such as the institutional structure and its bureaucratisation, as well as the
strict hierarchy that exists among professionals in hospitals. Hierarchy often results in the abuse of power and
this then results in internal conflicts, more or less open,
and, in other cases, invisible [29].
The nurses feel that they are the patients’ advocates
and they cannot simply be governed by f
