Bioethics and Neurosurgery: An Overview of Existing and Emerging Topics for the Practicing Neurosurgeon

Neurosurgery is a field with complex ethical issues. In this article, we aim to provide an overview of key and emerging ethical issues in neurosurgery with a focus on issues relevant to practicing neurosurgeons. These issues include those of informed consent, capacity, clinical trials, emerging neurotechnology, innovation, equity and justice, and emerging bioethics areas including community engagement and organizational ethics. We argue that bioethics can help neurosurgeons think about and address these issues, and, in turn, the field of bioethics can benefit from engagement by neurosurgeons. Several ideas for increasing engagement in bioethics are proposed.

Ethical issues in the operating room: A scoping review

BACKGROUND

For the patients receiving care in the operating room, it emphasizes that the ethical behavior and attitude of health professionals should be aligned with patients' basic human rights. Surgical ethics may provide an ethical alternative in a specific operating room context. However, it is unclear how actively research is being conducted in this regard.

AIM

This study determines the direction of future research by identifying ethical issues experienced in the operating room.

METHOD

This scoping review is based on the methodological framework suggested by Arksey and O'Malley in 2005. PubMed, CINAHL, EMBASE, WOS, Cochrane, KISS, and KMbase databases were searched from January 2012 to May 2022. Two researchers independently screened the searched articles by reviewing the titles, abstracts, and full texts. Consequently, 19 studies were selected.

FINDINGS

Five categories were identified: Professional ethics, Organizational ethics, Patients' rights, Patient safety, and Allocating resources. The derived categories covered all the same content as the International Council of Nurses' (ICN) code of ethics, with the exception of one element, that is, global health.

CONCLUSIONS

This study highlights ethical issues in the operating theatre and emphasizes the need for individual and organizational strategies aligned with the ICN code of ethics. Future research should cover a wider range of issues, employ diverse perspectives and methodologies, and enhance ethical practices to improve understanding and ethical practices in the field.

Organizational Ethics in Healthcare: A National Survey

Organizational ethics-defined as the alignment of an institution's practices with its mission, vision, and values-is a growing field in health care not well characterized in empirical literature. To capture the scope and context of organizational ethics work in United States healthcare institutions, we conducted a nationwide convenience survey of ethicists regarding the scope of organizational ethics work, common challenges faced, and the organizational context in which this work is done. In this article, we report substantial variability in the structure of organizational ethics programs and the settings in which it is conducted. Notable findings included disagreement about the activities that comprise organizational ethics and a lack of common metrics used to assess organizational ethics activities. A frequently cited barrier to full engagement in these activities was poor institution-wide understanding about the role and function of organizational ethics resources. These data suggest a tension in the trajectory of organizational ethics' professionalization: while some variability is appropriate to the field's relative youth, inadequate attention to definitions of organizational ethics practice and metrics for success can impede discussions about appropriate institutional support, leadership context, and training for practitioners.

The predictive factors of moral courage among hospital nurses

BACKGROUND

Having moral courage is a crucial characteristic for nurses to handle ethical quandaries, stay true to their professional obligations towards patients, and uphold ethical principles. This concept can be influenced by various factors including personal, professional, organizational, and leadership considerations. The purpose of this study was to explore the predictors of moral courage among nurses working in hospitals.

METHODS

In 2018, an observational cross-sectional study was carried out on 267 nurses employed in six hospitals located in the northern region of Iran. The participants were selected through a simple random sampling technique. To collect data, a demographic information form was used along with two questionnaires. The first questionnaire was a standard survey on moral courage, while the second questionnaire was designed to assess the ethical climate. Linear regression was used to assess the predictors of moral courage.

RESULTS

Nurses had an average moral courage score of 87.07 ± 15.52 and an average moral climate score of 96.12 ± 17.17. The study showed that 16% of the variation in moral courage scores among nurses was explained by ethical climate and monthly overtime hours.

CONCLUSION

This study underscores the significance of establishing an ethical work environment and minimizing overtime hours in order to enhance moral courage among nurses. These findings carry weight for both nursing practice and organizational policies focused on fostering ethical conduct within healthcare settings.

Applying a systems oriented ethical decision making framework to mitigating social and structural determinants of health

Objectives

Clinical ethical decision-making models are largely geared toward individual clinician choices and individual patient outcomes, not necessarily accounting for larger systemic issues that affect optimal patient outcomes. The purpose of this paper is to provide an ethical decision-making model, drawing upon systems orientation and ethical theory, specifically incorporating and aiding in the mitigation of social and structural determinants of health.

Methods

This paper presents a systems-oriented ethical decision-making framework derived from the analysis and critique of the Four-Box Method for Ethical Decision-Making by Jonsen, Siegler, and Winslade. Drawing upon both deontological and utilitarian ethical theory, the developed framework will assist providers, organizations, and health system leaders in navigating the increasingly complex ethical dimensions of care delivery for underserved patient populations, who are largely impacted by social and structural determinants of health.

Results

The needs of underserved patients are inextricably linked to various social and structural determinants of health that, if left unaddressed, result in even poorer health outcomes, exacerbating existing health disparities. A systems-oriented ethical decision-making framework, centered on obligation, duty, and a utilitarian view of the optimal good, will aid providers, organizations, health system leaders, and community stakeholders in navigating the increasingly complex ethical dimensions of care delivery for underserved patient populations.

Conclusion

Socioeconomic and political contexts have a significant impact on the way society is organized, how people are positioned in society, and how they will fare in terms of their health. Healthcare providers, including dentists, are largely unaware of and insensitive to the social issues that underlie the biological or psychological concerns that patients from socially disadvantaged backgrounds face. A systems-oriented ethical decision-making model will aid in mitigating social and structural determinants of health and the dental profession's obligations to the underserved.

[Nursing ethics and the mandate of care-current limits using the example of inpatient care for the elderly]

The central guiding ethical principles of professional care are dignity, care, justice, and respect. The current framework conditions and circumstances in the care of the elderly mean that professional care ethics are no longer feasible in many cases. This leads not only to enormous (moral) burdens among the nursing staff, but also to a comprehensive degree to professional dissatisfaction and to leaving the profession. The term "Pflexit" (based on the German word "Pflege" = care) was first raised during the corona pandemic and has not faded. In order to ensure ethically justified and dignified care for the elderly that is also oriented towards human rights, as is conveyed politically in charters and rightly expected by people in need of care, rapid and comprehensive social and political intervention is required.In this context, dignity and respect are also a social mandate. Dignified professional care based on ethical values can only be implemented if nurses are shown this same respect. The clear warnings of a "nursing climate crisis" must finally be followed by action to stop the exodus from the profession. In this discussion paper, the importance of a professional care ethic is first explained. In a second step, the framework and current problems that oppose a comprehensive implementation of core values in nursing care for the elderly are highlighted. The focus here is on the effects of the precarious personnel situation.

Mitigating Moral Distress in Leaders of Healthcare Organizations: A Scoping Review

GOAL

Moral distress literature is firmly rooted in the nursing and clinician experience, with a paucity of literature that considers the extent to which moral distress affects clinical and administrative healthcare leaders. Moreover, the little evidence that has been collected on this phenomenon has not been systematically mapped to identify key areas for both theoretical and practical elaboration. We conducted a scoping review to frame our understanding of this largely unexplored dynamic of moral distress and better situate our existing knowledge of moral distress and leadership.

METHODS

Using moral distress theory as our conceptual framework, we evaluated recent literature on moral distress and leadership to understand how prior studies have conceptualized the effects of moral distress. Our search yielded 1,640 total abstracts. Further screening with the PRISMA process resulted in 72 included articles.

PRINCIPAL FINDINGS

Our scoping review found that leaders-not just their employees- personally experience moral distress. In addition, we identified an important role for leaders and organizations in addressing the theoretical conceptualization and practical effects of moral distress.

PRACTICAL APPLICATIONS

Although moral distress is unlikely to ever be eliminated, the literature in this review points to a singular need for organizational responses that are intended to intervene at the level of the organization itself, not just at the individual level. Best practices require creating stronger organizational cultures that are designed to mitigate moral distress. This can be achieved through transparency and alignment of personal, professional, and organizational values.

A Study of How Moral Courage and Moral Sensitivity Correlate with Safe Care in Special Care Nursing

Background

Nursing is a caring profession, and nurses who have moral sensitivity and moral courage presumably can provide safe and better care for patients. This study aims at investigating how moral courage and moral sensitivity correlate with safe care in special care nursing.

Methods

This study is a descriptive work of research. The participants consisted of 524 nurses who were in practice in the ICU (intensive care unit), CCU (C\coronary care unit), post-CCU (postcoronary care unit), and dialysis of four hospitals located in the south of Iran selected via census sampling. Data were collected from April to September 2020 using the moral sensitivity questionnaire (MSQ), professional moral courage questionnaire (PMCQ), and the assessment of safe nursing care questionnaire (ASNCQ). The collected data were analyzed using descriptive statistics, t-test, chi-square, multiple regression analysis, and Pearson's correlation coefficient in SPSS v. 22.

Results

The mean ± SD of the nurses' age was 33.89 ± 6.91 years, and the mean ± SD of their work experience was 9.16 ± 4.67 years. The total mean score ± SD of the nurses' moral sensitivity was found to be 93.41 ± 2.68, the total mean score ± SD of their moral courage was found to be 96.38 ± 3.63, and the total mean score ± SD of their safe care scores was found to be 321.80 ± 9.76. The values of Pearson's correlation coefficients showed significant correlations between moral courage and safe care (r = 0.54, p < 0.001), moral sensitivity and safe care (r = 0.59, p < 0.001), and moral sensitivity and moral courage (r = 0.52, p < 0.001).

Conclusion

There is a positive correlation between moral sensitivity and moral courage. Both positively correlated with special care nursing. Accordingly, through effective planning, education, and giving their support, nurse administrators can promote the abovementioned ethical virtues in the nursing staff, thereby improving the quality of care.

Determinants of Moral Distress Among Mental Health Professionals

Background:

It is assumed that understanding moral distress and its correlated factors among mental health professionals would enhance understanding of the ethical dilemmas that mental health professionals are confronting.

Objectives:

To identify moral distress determinants among Jordanian mental health professionals working in psychiatric in-patient settings.

Methods:

A cross-sectional descriptive design was used, employing self-administered questionnaire.

Results:

Two- steps multiple hierarchical regression analysis showed that model 1 that includes the demographic characteristics, was significant with R2 = .151, while in model 2 that included demographics and the psychological characteristics of stress factors, it was found to be also significant R2 = .243.

Conclusion:

Morally distressing environments might diminish the quality of psychiatric care provided as well as the job satisfaction among healthcare providers.

Determinants of Moral Distress Among Mental Health Professionals

Background:

It is assumed that understanding moral distress and its correlated factors among mental health professionals would enhance understanding of the ethical dilemmas that mental health professionals are confronting.

Objectives:

To identify moral distress determinants among Jordanian mental health professionals working in psychiatric in-patient settings.

Methods:

A cross-sectional descriptive design was used, employing self-administered questionnaire.

Results:

Two- steps multiple hierarchical regression analysis showed that model 1 that includes the demographic characteristics, was significant with R2 = .151, while in model 2 that included demographics and the psychological characteristics of stress factors, it was found to be also significant R2 = .243.

Conclusion:

Morally distressing environments might diminish the quality of psychiatric care provided as well as the job satisfaction among healthcare providers.

Iranian nurses' views on barriers to moral courage in practice: A qualitative descriptive study

Background

Nursing is a caring profession. Due to the nature of their work, nurses need to have the moral courage to deliver safe nursing care. Research results have reported a low level of moral courage in the majority of nurses. The current study aimed to identify the barriers to show moral courage in Iranian nurses.

Methods

This study was qualitative research that was conducted using conventional content analysis. Data was gathered using in-person, semi-structured, in-depth interviews. Interviews were conducted from March to September 2020. Purposeful sampling was used and sampling was continued until data saturation was reached. Participants were 19 nurses working in hospitals in Iran.

Results

According to data analysis, six categories and three themes were extracted. Themes are “organizational failure”, “deterrent personal identity” and “defeated professional identity”.

Conclusions

The results of this study revealed the barriers to show moral courage which were usually overlooked in previous quantitative studies. It appears that the elimination of these barriers is an effective step in the improvemalet of nurses’ competencies. The results of this study can be helpful in the developmalet of programs to address the factors affecting nurses’ moral courage.

[Miserable conditions in hospitals, institutional pathologies and clinical organizational ethics]

Personal und Patienten in Einrichtungen organisierter Krankenbehandlung erfahren und bekunden vielfältige miserable Zustände dieser Organisationen. Einige „Miseren“ lassen sich im Rahmen einer Theorie institutioneller Pathologien als störende Auswirkungen der Aktivitäten und Strukturen von Organisationen des Politiksystems (Gesundheitspolitik) und des Wirtschaftssystems (Gesundheitswirtschaft) erklären. Deshalb können Klinische Ethik-Komitees (KEKs) solchen Miseren nicht wirksam begegnen oder sie sogar nicht einmal thematisieren. Organisationsethik kann sie thematisieren, aber ihnen nicht wirksam begegnen. Vorgeschlagen wird die Verstärkung von Organisationethik durch eine Theorie institutioneller Pathologie. Institutionspathologisch aufgeklärte, „klinische“ Organisationsethik kann helfen, in Ethiktheorie und Praxis, etwa für Mitglieder von KEKs und Organisationethikberater, die Möglichkeiten der Beobachtung, Bewertung und ggf. Besserung von gestörten Verantwortungsverhältnissen erheblich zu erweitern.

[]"Sacred encounters" in primary care: What do they mean for family physicians?]

OBJECTIVE

To determine the perceptions and attitudes of the general practitioners (GP) towards consultations with great emotional component, initially called "sacred encounters", and to identify areas of improvement.

DESIGN

A qualitative methodology based on a socio-subjective approach and focused on health services research. Descriptive-interpretative study.

LOCATION

Health Centres of Alava and Biscay.

PARTICIPANTS

Selection of 23 GP from 23 urban and rural Health Centres.

METHOD

Intentional sampling aimed at looking for discursive diversity. Data generated in 2016 by means of 3 discussion groups and 3 individual interviews recorded and transcribed after informed consent. Presentation to the ethics committee of the Basque Country. Thematic analysis with the aid of conceptual maps and MaxQDA program. Triangulation of the results between researchers and verification by the participants.

RESULTS AND DISCUSSION

The findings were clustered into overlapping thematic areas related to the meaning of these encounters, attitudes of GP, health context, and patients. The importance of the emotions in primary care encounters and their invisibility is underlined, but the adequacy of the term "sacred" is questioned. This expression is built into the GP-patient relationship, if GP favours it and the patient also allows it, discussing the main circumstances that intervene in an essential dimension of integral care.

CONCLUSIONS

The attention to the emotional dimension in the encounters has deficiencies that need to be corrected. In addition to its recognition and evaluation, it would be necessary to modify the organisational, training and professional factors that determine the involvement of the GPs in their good health care.

Patients’ rights and professional conduct issues in hospitals’ codes of ethics

Purpose

The purpose of this study is to explore the presence of ethical standards in the content of international hospitals codes of ethics disclosed in their websites.

Design/methodology/approach

Firstly, the focus is on developing an integrated framework of universal values and hospital responsibilities for the content of hospitals’ codes of ethics documents. A list of key ethical issues was determined through an examination of the American Medical Association Code of Medical Ethics (2016), the WAMA (2017), International Code of Medical Ethics and relevant peer-reviewed journal articles (Finseschi, 1997; Vergallo, 2016; Suhonen et al., 2011; Reader et al., 2014). Based on the detailed literature review, 48 concepts, which were evenly, classified under two groups; professional conduct issues and patients’ rights. In the second stage, the issues were ranked related to professional conduct and patients’ rights from most to least frequent for the proposed conceptual framework, using World Global Hospitals codes of ethics.

Findings

It was found that only 62% of the top 100 hospitals have an ethics code report in their websites. The findings of the study have significant theoretical and practical implications. First, most of the hospitals’ ethical codes extensively emphasize professional conduct and patients’ rights, whereas they differ in what they include or exclude from their codes and the wording used. The number and frequency of the professional conduct issues is higher than patients’ rights. Emerging ethical issues, such as physicians’ and patients’ freedom of choice, sperm donation and artificial reproduction, were not widely mentioned, whereas abortion, euthanasia, human rights and transplantation issues were disregarded entirely.

Practical implications

This study provides a benchmark for hospitals to assess their codes against other hospitals’ codes in terms of the specific items they address.

Social implications

The results of this study provide a benchmark for evaluating and developing ethical codes for hospitals in light of the international health standards and norms.

Originality/value

To the best of the knowledge, no previous study has theoretically or practically analyzed hospitals’ codes of ethics.

Exploring the Human Factors Affecting Health Service Managers: A Qualitative Study

BACKGROUND

In recent decades, managing health-service systems has faced multiple challenges. Identifying and resolving these challenges promote the efficiency and effectiveness of hospital activities.

AIM

The present study aimed to explore the human factors affecting health service managers.

MATERIAL AND METHODS

In this qualitative study, in-depth unstructured interviews were conducted with 29 employees who were in close contact with the health service managers. All the interviews were transcribed verbatim. Data were collected using purposeful sampling and were analysed using conventional content analysis via MAXQDA software.

RESULTS

A group of 29 participants were interviewed (male 65.5%, female 34.4%). "Managing managers" has been identified as the primary theme with four supporting secondary themes including the inappropriate appointment of managers, the impact of human and social needs of managers, influential employees, and disrupting organisational communications. These are the challenges faced by managers in managing human resources in health-service organisations.

CONCLUSION

Results showed that employees manage their managers within the organisation so that they can prevent managers from concentrating on their management affairs and tasks resulting in the distortion of management practices. The results of this study can help the key policy makers and planners in health-service organisations to guide the organisation to pursue its goals through appointing appropriate managers and identifying influential employees.

'You can give them wings to fly': a qualitative study on values-based leadership in health care

BACKGROUND

Within contemporary health care, many of the decisions affecting the health and well-being of patients are not being made by the clinicians or health professionals, but by those involved in health care management. Existing literature on organizational ethics provides insight into the various structures, processes and strategies - such as mission statement, ethics committees, ethical rounds … - that exist to create an organizational climate, which fosters ethical practices and decision-making It does not, however, show how health care managers experience their job as being intrinsically ethical in itself. In the present article, we investigate the way in which ethical values are present in the lived experiences and daily practice of health care management. What does it imply to take up a managing position within a health care institution and to try to do this in an ethically inspired way?

METHOD

We carried out a qualitative study (Grounded Theory Approach) to explore the essence of values-based leadership in health care. We interviewed 15 people with extensive experience in health care management in the fields of elderly care, hospital care and mental health care in the various regions of Flanders, Belgium.

RESULTS

Six predominant themes, presented as metaphors, illustrate the essence of values-based leadership in health care management. These are: (1) values-based health care management as managing a large garden, (2) as learning and using a foreign language, (3) going on a trekking with an ethical compass, (4) embodying integrity and authenticity in a credible encounter with everyone, (5) being a present and trustworthy leader during sun and storm, and (6) contributing to human flourishing by giving people wings to fly.

CONCLUSIONS

Notwithstanding the importance of organizing a good ethics infrastructure, values-based leadership in health care entails much more than that. It is about the co-creation of an integrated and comprehensive ethical climate of which community-model thinking and authentic leadership are essential components. As a never-ending process, the six metaphors can help leaders to take substantive proactive steps to shape a fruitful ethical climate within their organization.

Healthcare professionals' ethical competence: A scoping review

AIM

The aim of this study was to examine the extent and nature of the available research literature on healthcare professionals' ethical competence and to summarize the research findings in this field.

DESIGN

A scoping review guided by Arksey and O'Malleys methodological framework was conducted.

METHODS

Six databases including Pubmed/Medline, CINAHL, Web of Science Core Collection, PsycInfo, Philosophers' Index, and Scopus were searched systematically. Of 1,476 nonduplicate citations, 17 matched the inclusion criteria.

RESULTS

Findings revealed that healthcare professionals' ethical competence is a limited but topical research area. The focus areas of the studies were conceptualization, measuring, and realization of the ethical competence. The studies provided varying definitions and constructions for ethical competence and a few instruments to measure ethical competence were identified. Research in this area seems to be in a transition phase from theorization to empirical measurement. Methodologically, the research was rather heterogeneous and mainly focused on nurses.

Narrative writing as a strategy for nursing ethics education in Japan

OBJECTIVES

The purpose of this study was to explore the effectiveness of learning ethics of nursing practice using narrative writing.

METHODS

Study design was qualitative descriptive research. The participants were 90 graduate students who took nursing ethics classes, of whom 86 graduate students (4 males and 82 females) agreed to this study. The data gathered for analysis were their narratives described as feeling uncomfortable in clinical settings and their comment sheets after narrative group work in nursing ethics classes. We used qualitative content analysis to identify graduate students' awareness gained through narrative writing and narrative group work.

RESULTS

As a feature of the scenes described by graduate students, there were often conflicts that patients' autonomy were not respected, or that they were not able to engage in sincere engagement. The narrative writing was effective to make graduate students aware of the following two aspects: 1) habits and trends in one's own thoughts and 2) organizational and administrative issues related to ethical issues.

CONCLUSIONS

Learning ethics of nursing practice using narrative writing that focused on nurses' sentiments helped reveal nurses' thoughts as well as their attitudes and approaches to patients. These findings suggest that narrative writing in nursing ethics education could lead to ethical practice. Additionally, our results indicate that narrative writing in research may be helpful as a strategy to clarify ethical issues and the awareness of nurses in clinical settings.

Nursing managers attitude toward spirituality and spiritual care in Khorasan Razavi Province hospitals in 2016

Background and aim

Spiritual care is an important part of nursing practice that seems to provide comprehensive care to patients. Nursing manager’s attention to the spiritual dimension is one of the most important aspects affecting human health. Therefore, the aim of this study was to determine nursing managers’ attitude to spirituality and spiritual care in hospitals in Khorasan Razavi Province in 2016.

Methods

In this cross-sectional study, 110 management nurses (8 matrons, 37 supervisors and 65 head nurses) of hospitals in Khorasan Razavi Province (2016) were recruited for the study. Data were collected using a Spirituality & Spiritual Care Rating Scale (SSCRS) questionnaire in two parts, demographic information and questions related to the research objectives. Data were collected and analyzed using SPSS 16 software and doing descriptive (frequency, mean, standard deviation) and inferential statistics (independent-samples t-test, ANOVA) and considering levels of significance (p<0.05).

Results

The results showed mean and standard deviation in management nursing attitude to spirituality (4.01±0.35) and spiritual care (4.03±0.78). The result showed significant differences between the attitude to spirituality and spiritual care and gender, age and work experience in nursing management (p<0.05).

Conclusions

Management nursing has high level attitude to spirituality and spiritual care. Therefore, providing the perfect platform to provide this care, and for nurses to implement it in hospitals is recommended.

Resource allocation and rationing in nursing care: A discussion paper

Driven by interests in workforce planning and patient safety, a growing body of literature has begun to identify the reality and the prevalence of missed nursing care, also specified as care left undone, rationed care or unfinished care. Empirical studies and conceptual considerations have focused on structural issues such as staffing, as well as on outcome issues - missed care/unfinished care. Philosophical and ethical aspects of unfinished care are largely unexplored. Thus, while internationally studies highlight instances of covert rationing/missed care/care left undone - suggesting that nurses, in certain contexts, are actively engaged in rationing care - in terms of the nursing and nursing ethics literature, there appears to be a dearth of explicit decision-making frameworks within which to consider rationing of nursing care. In reality, the assumption of policy makers and health service managers is that nurses will continue to provide full care - despite reducing staffing levels and increased patient turnover, dependency and complexity of care. Often, it would appear that rationing/missed care/nursing care left undone is a direct response to overwhelming demands on the nursing resource in specific contexts. A discussion of resource allocation and rationing in nursing therefore seems timely. The aim of this discussion paper is to consider the ethical dimension of issues of resource allocation and rationing as they relate to nursing care and the distribution of the nursing resource.

The mediating effect of ethical climate on religious orientation and ethical behavior

Background:

Nurses’ behavior in Educational-Medical centers is very important for improving the condition of patients. Ethical climate represents the ethical values and behavioral expectations. Attitude of people toward religion is both intrinsic and extrinsic. Different ethical climates and attitude toward religion could be associated with nurses’ behavior.

Aim:

To study the mediating effect of ethical climate on religious orientation and ethical behaviors of nurses.

Research design:

In an exploratory analysis study, the path analysis method was used to identify the effective variables on ethical behavior.

Participants/context:

The participants consisted of 259 Iranian nurses from Hamadan University of Medical Sciences.

Ethical considerations:

This project with an ethical code and a unique ID IR.UMSHA.REC.1395.67 was approved in the Research Council of Hamadan University of Medical Sciences.

Findings:

The beta coefficients obtained by regression analysis of perception of ethical climate of individual egoism (B = −0.202, p < 0.001), individual ethical principles (B = −0.184, p = 0.001), local egoism (B = −0.136, p = 0.003), and extrinsic religious orientation (B = −0.266, p = 0.007) were significant that they could act as predictors of ethical behavior. The summary of regression model indicated that 0.27% of ethical behaviors of nurses are justified by two variables: ethical climate and religious orientation.

Discussion and conclusion:

Intrinsic religious orientation has the most direct impact and then, respectively, the variables of ethical climate of perceptions in the dimensions of individual egoism, individual ethical principles, local egoism, global ethical principle, and ethical behavior and extrinsic religious orientation follow. All the above, except global ethical principles and intrinsic orientation of religion have a negative effect on ethical behavior and can be predictors of ethical behavior. Therefore, applying strategies to promote theories of intrinsic religious orientation and global ethical principles in different situations of nursing is recommended.

Ethical climate in nursing environment: A scoping review

Background:

In the past two decades, interest in the concept of ethical climate and in its research has increased in healthcare. Ethical climate is viewed as a type of organizational work climate, and defined as the shared perception of ethically correct behavior, and how ethical issues should be handled in the organization. Ethical climate as an important element of nursing environment has been the focus of several studies. However, scoping reviews of ethical climate research in nursing have not been conducted to guide further research in this area.

Objective:

The purpose of this scoping review is to describe and analyze studies focusing on ethical climate in nursing environment to elicit an overall picture of the research in this field.

Methods:

A scoping review methodology guided by Arksey and O’Malley and Levac et al. was used. Studies were identified by conducting electronic searches on PubMed/MEDLINE, CINAHL, Web of Science Core Collection, PsycINFO, and Scopus and Philosophers’ Index databases. Of 1051 citations, 56 articles matched the inclusion criteria.

Ethical considerations:

This study was conducted according to good scientific guidelines.

Findings:

Ethical climate is a topical research area which has been explored with different methods and outcomes, in different environments, and has mainly been perceived positively. The focus of the studies was on finding associations between ethical climate and work-related factors such as job satisfaction, moral distress, and turnover intentions. Methodologically, research was rather homogeneous using quantitative, descriptive, and correlative research designs.

Conclusion:

Novel perspectives and more diverse methodological approaches paying attentions to issues affecting generalizability of the findings could expand our knowledge in this area.

Ethics interventions for healthcare professionals and students: A systematic review

Background:

The ethics and value bases in healthcare are widely acknowledged. There is a need to improve and raise awareness of ethics in complex systems and in line with competing needs, different stakeholders and patients’ rights. Evidence-based strategies and interventions for the development of procedures and practice have been used to improve care and services. However, it is not known whether and to what extent ethics can be developed using interventions.

Objectives:

To examine ethics interventions conducted on healthcare professionals and healthcare students to achieve ethics-related outcomes.

Research design:

A systematic review.

Methods:

Five electronic databases were searched: CINAHL, the Cochrane Library, Philosopher’s Index, PubMed and PsycINFO. We searched for published articles written in English without a time limit using the keywords: ethic* OR moral* AND intervention OR program OR pre-post OR quasi-experimental OR rct OR experimental AND nurse OR nursing OR health care. In the four-phased retrieval process, 23 full texts out of 4675 citations were included in the review. Data were analysed using conventional content analysis.

Ethical consideration:

This systematic review was conducted following good scientific practice in every phase.

Findings:

It is possible to affect the ethics of healthcare practices through professionals and students. All the interventions were educational in type. Many of the interventions were related to the ethical or moral sensitivity of the professionals, such as moral courage and empowerment. A few of the interventions focused on identifying ethical problems or research ethics.

Conclusion:

Patient-related outcomes followed by organisational outcomes can be improved by ethics interventions targeting professionals. Such outcomes are promising in developing ethical safety for healthcare patients and professionals.

Ethos: The heart of ethics and health

Background:

Ethics in nursing care are traditionally discussed in terms of moral norms or principles. When taking an ontological approach to ethics, ethics is about ethos. Ethos involves both an internal and an external side of ethics. Considering ethics and health from an ontological perspective can provide a different understanding of ethics and health in caring and nursing.

Aim and research question:

The aim of this study is to deepen the ontological understanding of ethics and health in caring and nursing. The research question is as follows: What is the ontology of health and ethics in caring and nursing?

Research design:

The study follows a hermeneutical design inspired by Gadamer. Participants and research context: essays about ethics and health were gathered from PhD students in nursing and caring sciences.

Ethical considerations:

The research follows Responsible conduct of research guidelines provided by the Finnish Advisory Board on Research Integrity.

Findings:

An ethos with the values of freedom and responsibility seem to ontologically be important for ethics and health. These values allow a movement between the internal and the external sides of ethics that is important for health.

Discussion:

The ethos of freedom and responsibility that is essential for ethics and health can provide the current ethical debate a new starting point that previous research asks for.

Conclusion:

Ontologically, an ethos of freedom and responsibility is essential for ethics and health in nursing and caring.

Validation of an instrument to measure moral distress within the Australian residential and community care environments

AIM AND OBJECTIVES

The aim of this study was to gain insight into the experience of moral distress within the aged care workforce. The objective of this study was to use and validate an existing instrument to measure moral distress within the aged care setting.

BACKGROUND

Moral distress, a phenomenon associated with worker satisfaction and retention, is common within nursing. Instruments to measure moral distress exist; however, there are no validated instruments to measure moral distress within an aged care setting.

DESIGN AND METHOD

An existing instrument, the Moral Distress Scale (Revised) was identified and amended. Amendments were subject to expert review for face and content validity. Data were collected from aged care nurses working in residential and community aged care, in Australia. Reliability was assessed using Cronbach's alpha with exploratory factor analysis undertaken for construct validity.

RESULTS

106 participants completed the survey, 93 (87.7%) identified as female and 13 (12.3%) male. Participants ranged in age from 21 to 73 years, with a mean time working in nursing of 20.6 years. The frequency component of the instrument demonstrated an alpha of 0.89, the intensity component 0.95 and the instrument as a whole 0.94. Three factors were identified and labelled as: Quality of Care, Capacity of Team and Professional Practice. Mean scores indicate a low occurrence of moral distress, but this distress, when experienced, was felt with a moderate level of intensity. Primary causes of moral distress were insufficient staff competency levels, poor quality care because of poor communication and delays in implementing palliation.

CONCLUSION

The instrument demonstrates validity and reliability within the Australian aged care setting. Further analysis with larger populations is required to support these findings.

IMPLICATIONS FOR PRACTICE

Australian aged care workers do experience moral distress. They suffer adverse consequences of this distress and quality of care is negatively impacted. This newly validated instrument can be used to quantify the occurrence of moral distress and to inform targeted interventions to reduce the occurrence and intensity of the experience.

Educating for ethical leadership through web-based coaching

Background:

Ethical leadership is important for developing ethical healthcare practice. However, there is little research-based knowledge on how to stimulate and educate for ethical leadership.

Objectives:

The aim was to develop and investigate the feasibility of a 6-week web-based, ethical leadership educational programme and learn from participants’ experience.

Training programme and research design:

A training programme was developed consisting of (1) a practice part, where the participating middle managers developed and ran an ethics project in their own departments aiming at enhancing the ethical mindfulness of the organizational culture, and (2) a web-based reflection part, including online reflections and coaching while executing the ethics project. Focus group interviews were used to explore the participants’ experiences with and the feasibility of the training.

Participants and research context:

Nine middle managers were recruited from a part-time master’s programme in leadership in Oslo, Norway. The research context was the participating leaders’ work situation during the 6 weeks of training.

Ethical considerations:

Participation was voluntary, data anonymized and the confidentiality of the participating leaders/students and their institutions maintained. No patient or medical information was involved.

Findings:

Eight of the nine recruited leaders completed the programme. They evaluated the training programme as efficient and supportive, with the written, situational feedback/coaching as the most important element, enhancing reflection and motivation, counteracting a feeling of loneliness and promoting the execution of change.

Discussion:

The findings seem consistent with the basic assumptions behind the educational design, based partly on e-health research, feedback studies and organizational ethics methodology, partly on theories on workplace learning, reflection, recognition and motivation.

Conclusion:

The training programme seems feasible. It should be adjusted according to participants’ proposals and tested further in a large-scale study.

Organisational and individual support for nurses’ ethical competence: A cross-sectional survey

Background:

Nurses’ ethical competence has been identified as a significant factor governing high quality of care. However, nurses lack support in dealing with ethical problems, and therefore managerial support for nurses’ ethical competence is needed.

Research questions:

This study aimed to analyse, from the perspective of nurse and nurse leaders, the level of nurses’ and nurse leaders’ ethical competence, perceptions of support for nurses’ ethical competence at the organisational and individual levels and background factors associated with this support.

Research design:

A descriptive, cross-sectional study design was employed. The Ethical Competence and Ethical Competence Support questionnaires were used to measure the main components. Descriptive statistics and multifactor analysis of variance were used for data analysis.

Participants:

The participants were 298 nurses and 193 nurse leaders working in specialised (48%/52%), primary (43%/36%) or private healthcare (5%/7%) in Finland.

Ethical considerations:

Ethical approval was obtained from the university ethics committee. Results: Nurses estimated their own ethical competence to be at an average level, whereas nurse leaders estimated their own competence at a high level. Nurses’ and nurse leaders’ perceptions of provided support for nurses’ ethical competence was not at a high level. The positive agreement percentage related to organisational support was 44% among nurses and 51% among nurse leaders. The positive agreement percentage related to individual support was lower, that is, 38% among nurses and 61% among nurse leaders. University education had a positive association with some items of individual support.

Conclusion:

Despite the findings that ethical competence was estimated at a high level among nurse leaders, perceptions of support for nurses’ ethical competence were not at a satisfactory level. At the organisational level, nurse leaders need to inform of ethical procedures and practices in orientation; encourage multidisciplinary ethics discussions and collaboration; and support nurses at an individual level to participate in ethics education, multidisciplinary ethics discussions and in solving ethical problems.

The workers opinions have a value in the Code of Ethics: Analysis of the contributions of workers in virtual Forum Catalan Institute of Health

Background

The Catalan Institute of Health (CIH) is the largest health services public provider in Catalonia. “CIH Code of Ethics Virtual Forum” (CEVF), was created within the Intranet of the CIH to facilitate participation among their employees. The current study aims to: a) Analyse the CIH workers’ assessment of their own, their colleagues’ and the organization’s observance of ethical values; b) Identify the opinions, attitudes, experiences and practices related to the ethical values from the discourse of the workers that contributed voluntarily to the CEVF.

Methods

Mixed methods study with convergent parallel design:

Cross sectional study by means of a self-administered, ad hoc, anonymous questionnaire to assess the observance of the ethical values of the CIH according to the participants. A total of 712 workers responded to the questionnaire. A descriptive, bivariate analysis of the results was carried out.

Qualitative study to determine the meaning for the workers of the ethical values put forward by the organization. Their individual opinions and experiences were explored by means of a thematic contents analysis of 225 comments posted in the CEVF.

The study was conducted between May and December 2008.

Results

The average score for observance of the CE by the respondents themselves was high (over 4/5), between 3.5-4/5 for the observance by their colleagues and close to 3/5 for the CIH management. These results do not change when we compare by gender, age group and professional discipline. The comments on the values are information-rich, they mirror the ethical environment of the institution and show various ethical dilemmas and suggestions.

Conclusions

Results show that it is feasible for a publicly funded health care organization to develop a CE with the participation of employees and the support of the management. Results underscore the relevance of this strategy for the implementation, improvement and update of the CE as a responsibility shared by all workers. Practices consistent with ethical values are rewarded by social approval, enhance employee’s confidence and coherence in decision-making and improve public engagement and institutional policies.

Moral sensitivity and moral distress in Iranian critical care nurses

BACKGROUND

Moral sensitivity is the foremost prerequisite to ethical performance; a review of literature shows that nurses are sometimes not sensitive enough for a variety of reasons. Moral distress is a frequent phenomenon in nursing, which may result in paradoxes in care, dealing with patients and rendering high-quality care. This may, in turn, hinder the meeting of care objectives, thus affecting social healthcare standards.

RESEARCH OBJECTIVE

The present research was conducted to determine the relationship between moral sensitivity and moral distress of nurses in intensive care units.

RESEARCH DESIGN

This study is a descriptive-correlation research. Lutzen's moral sensitivity questionnaire and Corley Moral Distress Questionnaire were used to gather data. Participants and research context: A total of 153 qualified nurses working in the hospitals affiliated to Shahid Beheshti University of Medical Sciences were selected for this study. Subjects were selected by census method. Ethical considerations: After explaining the objectives of the study, all the participants completed and signed the written consent form. To conduct the study, permission was obtained from the selected hospitals.

FINDINGS

Nurses' average moral sensitivity grade was 68.6 ± 7.8, which shows a moderate level of moral sensitivity. On the other hand, nurses also experienced a moderate level of moral distress (44.8 ± 16.6). Moreover, there was no meaningful statistical relationship between moral sensitivity and moral distress (p = 0.26).

DISCUSSION

Although the nurses' moral sensitivity and moral distress were expected to be high in the intensive care units, it was moderate. This finding is consistent with the results of some studies and contradicts with others.

CONCLUSION

As moral sensitivity is a crucial factor in care, it is suggested that necessary training be provided to develop moral sensitivity in nurses in education and practical environments. Furthermore, removing factors that contribute to moral distress may help decrease it in nurses.

What ethics for case managers? Literature review and discussion

BACKGROUND

Little is known about case managers' ethical issues and professional values.

OBJECTIVES

This article presents an overview of ethical issues in case managers' current practice. Findings are examined in the light of nursing ethics, social work ethics and principle-based biomedical ethics.

RESEARCH DESIGN

A systematic literature review was performed to identify and analyse empirical studies concerning ethical issues in case management programmes. It was completed by systematic content analysis of case managers' national codes of ethics.

FINDINGS

Only nine empirical studies were identified, eight of them from North America. The main dilemmas were how to balance system goals against the client's interest and client protection against autonomy. Professional codes of ethics shared important similarities, but offered different responses to these two dilemmas.

DISCUSSION

We discuss the respective roles of professional and organizational ethics. Further lines of research are suggested.

Researching moral distress among New Zealand nurses: a national survey

BACKGROUND

Moral distress has been described as a major problem for the nursing profession, and in recent years, a considerable amount of research has been undertaken to examine its causes and effects. However, few research projects have been performed that examined the moral distress of an entire nation's nurses, as this particular study does.

AIM/OBJECTIVE

The purpose of this study was to determine the frequency and intensity of moral distress experienced by registered nurses in New Zealand.

RESEARCH DESIGN

The research involved the use of a mainly quantitative approach supported by a slightly modified version of a survey based on the Moral Distress Scale-Revised.

PARTICIPANTS AND RESEARCH CONTEXT

In total, 1500 questionnaires were sent out at random to nurses working in general areas around New Zealand and 412 were returned, giving an adequate response rate of 27%.

ETHICAL CONSIDERATIONS

The project was evaluated and judged to be low risk and recorded as such on 22 February 2011 via the auspices of the Massey University Human Ethics Committee.

FINDINGS

Results indicate that the most frequent situations to cause nursing distress were (a) having to provide less than optimal care due to management decisions, (b) seeing patient care suffer due to lack of provider continuity and (c) working with others who are less than competent. The most distressing experiences resulted from (a) working with others who are unsafe or incompetent, (b) witnessing diminished care due to poor communication and (c) watching patients suffer due to a lack of provider continuity. Of the respondents, 48% reported having considered leaving their position due to the moral distress.

CONCLUSION

The results imply that moral distress in nursing remains a highly significant and pertinent issue that requires greater consideration by health service managers, policymakers and nurse educators.

The ethics of advertising for health care services

Advertising by health care institutions has increased steadily in recent years. While direct-to-consumer prescription drug advertising is subject to unique oversight by the Federal Drug Administration, advertisements for health care services are regulated by the Federal Trade Commission and treated no differently from advertisements for consumer goods. In this article, we argue that decisions about pursuing health care services are distinguished by informational asymmetries, high stakes, and patient vulnerabilities, grounding fiduciary responsibilities on the part of health care providers and health care institutions. Using examples, we illustrate how common advertising techniques may mislead patients and compromise fiduciary relationships, thereby posing ethical risks to patients, providers, health care institutions, and society. We conclude by proposing that these risks justify new standards for advertising when considered as part of the moral obligation of health care institutions and suggest that mechanisms currently in place to regulate advertising for prescription pharmaceuticals should be applied to advertising for health care services more broadly.

Nursing organizational climates in public and private hospitals

Background:

Researchers study climate to gain an understanding of the psychological environment of organizations, especially in healthcare institutions. Climate is considered to be the set of recurring patterns of individual and group behaviour in an organization. There is evidence confirming a relationship between ethical climate within organizations and job satisfaction.

Objectives:

The aim of this study is to describe organizational climate for nursing personnel in public and private hospitals and to confirm the relationships among the climate variables of such hospitals.

Materials and methods:

A correlational study was carried out to measure the organizational climate of one public hospital and two private hospitals in Granada. The Work Environment Scale was used for data collection. The Work Environment Scale includes 10 scales, ranging from 0 to 9, which were used to evaluate social, demographic and organizational climate variables. In this study, 386 subjects were surveyed in three hospitals.

Results:

A total of 87% of the participants were female and 16% were male. Most participants were nurses (65.6%), followed by nursing aides (20%), and technicians (14.4%). The results obtained reflected different patterns of organizational climate formation, based on hospital type (i.e. public or private) within the Spanish context. Most of the dimensions were below the midpoint of the scale.

Discussion and conclusions:

In conclusion, in public hospitals, there is a greater specialization and the organizational climate is more salient than in the private hospitals. In addition, in the public hospitals, the characteristics of the human resources and their management can have a significant impact on the perception of the climate, which gives greater importance to the organizational climate as decisive of the ethical climate.

Take me to my leader: the importance of ethical leadership among formal nurse leaders

Although ethical leadership by formal nurse leaders is critical to enhancing ethical health-care practice, research has shown that many nurses feel unsupported by their leaders. In this article, we consider the limited attention directed toward ethical leadership of formal nurse leaders and how our own research on ethical nurse leadership compares to other research in this field. In searching Nursing Ethics since its inception 20 years ago, we found only a dozen articles that directly addressed this topic. We then reviewed nurses' professional codes of ethics in Canada and found significant retractions of ethical guidelines for formal nurse leaders' ethical responsibilities over the past decade. We began to seek explanations of why this is so and offer some recommendations for the study and enhancement of ethics for formal nurse leadership.

Moral distress in nursing

Moral distress has been widely reviewed across many care contexts and among a range of disciplines. Interest in this area has produced a plethora of studies, commentary and critique. An overview of the literature around moral distress reveals a commonality about factors contributing to moral distress, the attendant outcomes of this distress and a core set of interventions recommended to address these. Interventions at both personal and organizational levels have been proposed. The relevance of this overview resides in the implications moral distress has on the nurse and the nursing workforce: particularly in regard to quality of care, diminished workplace satisfaction and physical health of staff and increased problems with staff retention.

Care of the old-A matter of ethics, organization and relationships

The world stands on the threshold of a demographic revolution called global ageing. According to the World Health Organization (WHO), the population aged 60 and over is expected to increase from today's 650 million to an estimated 2 billion by 2050. Alongside demographic changes, dramatic changes can also be observed in older people's services. The shift has resulted in reduced government spending on caring for ill and frail older people in health care. Today, many governments have developed strategies to keep older people living well in their private home for as long as possible and have replaced long-term care institutions with residential homes. The aim of this study was to illuminate the meaning of caring for older people as experienced by health care students and professionals working in this field. Interviews were carried out with 17 women and one man, aged 21–65 years; six were Registered Nurses (RN), six were Enrolled Nurses (EN) and six were nursing students. The interviews were analyzed with a phenomenological hermeneutical approach and provided three themes and eight sub-themes: Ethical moral self with sub-themes “meeting the needs of the old”, “pliability towards the old”, and “difficulties in meeting aggressiveness”; Organizational and co-workers ethical moral actions with sub-themes, “co-workers who are offensive”, and “supportive and non-supportive leaders”: The relation with the old persons and their relatives with sub-themes “fellowship and closeness in the relation”, “uncertainty and fear in the relation”, and, “demands from the older persons’ close relatives”.