Maintaining moral integrity among primary care nurse practitioners

Primary care presents distressful moral problems for nurse practitioners who report frustration, powerlessness, changing jobs, and leaving advanced practice. An understanding of how nurse practitioners deal with moral problems in primary care is needed. The purpose of this study was to describe the process nurse practitioners use to manage moral problems commonly encountered in primary care. The aims were to identify the strategies nurse practitioners use, the influencing factors, and the consequences for nurse practitioners.; Using grounded theory methodology, 23 nurse practitioners were interviewed in individual, private, sessions, commenting on hypothetical situations from the literature depicting ethical issues common to primary care.; A theory of Maintaining Moral Integrity in the Face of Moral Conflict emerged consisting of the phases of encountering conflict, drawing a line, finding a way without phases of encountering conflict; drawing a line, finding a way without crossing the line, and evaluating actions. A critical juncture occurred in the last phase when nurse practitioners determined that either their integrity had been preserved, thus no distress was experienced, and actions taken to manage conflict were reinforced; or their integrity may have been compromised, in which case varying degrees of distress were experienced as self-doubt, regret, outrage, or frustration over external constraints. Nurse practitioners engaged in activities intended to ease distress and reconcile integrity, which involved reevaluating responses in the previous phases and engaging in strategies of avoiding, convincing oneself, or compensating. If reconciling was successful, nurse practitioners no longer experienced distress and actions taken to resolve conflict were reinforced. If unsuccessful, nurse practitioners continued to experience distress and, if not later reconciled, eventually resulted in completely removing themselves from the situation. Nurse practitioners varied in awareness and discord encountered in conflict, and in clarity, flexibility, and justification of the line they drew. Strategies included balancing, communicating, advocating, building relationships, and protecting oneself and were influenced by the nurse practitioner's value perspective, knowledge and experience, role and relationship with patients, and work environment.; What maintained moral integrity for one nurse practitioner did not necessarily maintain it for another. The more congruence between the nurse practitioner's values and those of the work environment, the greater was the ability to maintain integrity.