Palliative care for homeless and vulnerably housed people: scoping review and thematic synthesis

INTRODUCTION

People who are homeless or vulnerably housed are subject to disproportionately high risks of physical and mental illness and are further disadvantaged by difficulties in access to services. Research has been conducted examining a wide range of issues in relation to end-of-life care for homeless and vulnerably housed people, however, a contemporary scoping review of this literature is lacking.

OBJECTIVES

To understand the provision of palliative care for people who are homeless or vulnerably housed from the perspective of, and for the benefit of, all those who should be involved in its provision.

DESIGN

Scoping review with thematic synthesis of qualitative and quantitative literature.

DATA SOURCES

MEDLINE, Embase, PsycINFO, Social Policy and Practice and CINAHL databases were searched, from inception to May 2020. Citation chasing and manual searching of grey literature were also employed.

RESULTS

Sixty-four studies, involving 2117 homeless and vulnerably housed people were included, with wide variation in methodology, population and perspective. The thematic synthesis identified three themes around: experiences, beliefs and wishes; relationships; and end-of-life care.

CONCLUSION

Discussion highlighted gaps in the evidence base, especially around people experiencing different types of homelessness. Existing evidence advocates for service providers to offer needs-based and non-judgemental care, for organisations to use existing assets in co-producing services, and for researchers to address gaps in the evidence base, and to work with providers in transforming existing knowledge into evaluable action.

Analysis of moral courage and related factors among undergraduate nursing students: a scoping review

OBJECTIVE

to analyze scientific evidence on moral courage and related factors among nursing undergraduate students.

METHOD

the protocol of this scoping review was registered on Open Science Framework. A search was performed in five databases, according to the method provided by Joanna Briggs Institute Reviewers, the mnemonic strategy Population, Concept and Context, and a specific checklist.

RESULTS

a total of 2,812 results were identified, but only nine studies were eligible and presented three thematic approaches: Moral courage from the perspective of nursing students; Moral courage and related factors; and The teaching of moral courage in the training of nursing students. The factors related to moral courage include moral distress, moral sensitivity, age, and having a previous degree in the health field.

FINAL CONSIDERATIONS

few studies were found with a low evidence level. Most were performed in developed countries, indicating some gaps that need to be addressed in the future.

Factors associated with the moral courage of nurses in China: A cross-sectional study

AIM

The purpose of this study was to assess the level of moral courage among nurses in China, and to explore related influential factors, to help nursing managers take measures to improve nurses' moral courage.

DESIGN

A cross-sectional study.

METHODS

The data adopted a convenient sampling method. From September to December 2021, 583 nurses from five hospitals in Fujian Province completed the Chinese version of the Nurses' Moral Courage Scale (NMCS). Data were analysed using descriptive statistics, chi-square test, T-test, Pearson correlation analysis and multiple regression analysis.

RESULTS

The Chinese nurses perceived themselves, on average, as morally courageous. The mean NMCS score was 3.64 ± 0.692. The six factors showed statistically significant correlations (p < 0.05) with moral courage. Regression analysis showed that the main factors influencing nurses' moral courage were active learning of ethics knowledge and nursing was a career goal.

CONCLUSION

This study provides the self-evaluation level and related influencing factors of Chinese nurses' moral courage. There is no doubt that nurses still need strong moral courage to face unknown ethical problems and challenges in the future. Nursing managers should pay attention to the cultivation of nurses' moral courage, using various forms of educational activities to help nurses alleviate moral problems and improve their moral courage, to maintain patients' access to high-quality nursing.

Moral sensitivity of nursing students. Adaptation and validation of the moral sensitivity questionnaire in Spain

Ethical sensitivity is a requirement for people care as well as for decision-making in everyday practice. The aim is to present an adaptation and transcultural validation -in Spanish- of the Moral Sensitivity Questionnaire by Lützén et al. in Spain. In addition to that, we provide a practical implementation analysing the degree of moral sensitivity of nursing students. The data used for data collection were moral Sensitivity Questionnaire, socio-demographic data and a self-report questionnaire. The psychometric properties of the questionnaire were assessed, including validity and reliability. Fit indices of the overall model were computed. The fit indices of the Confirmatory Factor Analysis (CFA) indicate a poor fit, although the Exploratory Factor Analysis (EFA) revealed two dimensions that show a better fit of its indices. Women and those women with more experience in the clinical setting have a higher mean score, as well as those who study in centers where the strategic lines are the humanization of care. Female nursing students with more experience in the clinical setting and with more educational training present higher sensitivity indexes, as well as those who study in centers where the strategic lines are the humanization of care. The findings confirm that the Lützén et al. questionnaire is multidimensional. In the Spanish sample, it was necessary to group the three initial factors into two: sense of moral burden and moral strength—grouping the moral responsibility items into the above items to make the instrument more resilient.

Validation of the Dutch-language version of Nurses' Moral Courage Scale

BACKGROUND

Moral courage as a part of nurses' moral competence has gained increasing interest as a means to strengthen nurses acting on their moral decisions and offering alleviation to their moral distress. To measure and assess nurses' moral courage, the development of culturally and internationally validated instruments is needed.

OBJECTIVE

The objective of this study was to validate the Dutch-language version of the four-component Nurses' Moral Courage Scale originally developed and validated in Finnish data.

RESEARCH DESIGN

This methodological study used non-experimental, cross-sectional exploratory design.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 559 nurses from two hospitals in Flanders, Belgium, completed the Dutch-language version of the Nurses' Moral Courage Scale.

ETHICAL CONSIDERATIONS

Good scientific inquiry guidelines were followed throughout the study. Permission to translate the Nurses' Moral Courage Scale was obtained from the copyright holder, and the ethical approval and permissions to conduct the study were obtained from the participating university and hospitals, respectively.

FINDINGS

The four-component 21-item, Dutch-language version of the Nurses' Moral Courage Scale proved to be valid and reliable as the original Finnish Nurses' Moral Courage Scale. The scale's internal consistency reliability was high (0.91) corresponding with the original Nurses' Moral Courage Scale validation study (0.93). The principal component analysis confirmed the four-component structure of the original Nurses' Moral Courage Scale to be valid also in the Belgian data explaining 58.1% of the variance. Confirmatory factor analysis based on goodness-of-fit indices provided evidence of the scale's construct validity. The use of a comparable sample of Belgian nurses working in speciality care settings as in the Finnish study supported the stability of the structure.

DISCUSSION AND CONCLUSION

The Dutch-language version of the Nurses' Moral Courage Scale is a reliable and valid instrument to measure nurses' self-assessed moral courage in speciality care nursing environments. Further validation studies in other countries, languages and nurse samples representing different healthcare environments would provide additional evidence of the scale's validity and initiatives for its further development.

Nurses' self-assessed moral courage and related socio-demographic factors

BACKGROUND

Nurses need moral courage to ensure ethically good care. Moral courage is an individual characteristic and therefore it is relevant to examine its association with nurses' socio-demographic factors.

OBJECTIVE

To describe nurses' self-assessed level of moral courage and its association with their socio-demographic factors.

RESEARCH DESIGN

Quantitative descriptive cross-sectional study. The data were collected with Nurses' Moral Courage Scale and analyzed statistically.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 482 registered nurses from a major university hospital in Southern Finland completed the Finnish language version of Nurses' Moral Courage Scale in autumn 2017.

ETHICAL CONSIDERATIONS

Ethical approval was obtained from the university ethics committee and permission for the data collection from the participating hospital. Ethical principles and scientific guidelines were followed throughout the research process.

FINDINGS

Nurses' self-assessed level of moral courage was rather high. On Visual Analogy Scale (0-10), the mean value was 8.20 and the mean score of the four dimensional, 21-item Nurses' Moral Courage Scale was 4.09 on a 5-point Likert-type scale. Respondents' gender, present work role, ethical knowledge base, additional ethics education, self-study as a means to acquire ethical knowledge, and frequency of work situations needing moral courage were statistically significantly associated with nurses' moral courage.

DISCUSSION

Strongest association was found between nurses' higher moral courage level and formal and informal ethics education. Honesty and patient's humane and dignified encounter received the highest scores indicating respondents' internalization of the core values of nursing.

CONCLUSION

Although nurses were fairly morally courageous, moral courage should be a part of nurses' basic and continuing education thus covering its theoretical and practical learning. Since moral courage is a virtue that can be taught, learnt, and practiced, education is a relevant way to maintain and further strengthen nurses' moral courage.

Moral courage in nursing - An integrative literature review

Moral courage and understanding of its meaning are essential when nurses face ethical conflicts in their practice. This integrative review aimed to explore moral courage in nursing and possible associated individual and organizational factors. A database search in January 2020 identified 1308 scientific articles of which 25 were selected for the review. Inductive analysis with clear steps for defining and synthesizing themes in research reviews revealed three categories concerning moral courage in nursing: definition and descriptions of moral courage, characteristics of the morally courageous nurse, and skills and acts of the morally courageous nurse. Individual and organizational factors, such as positive personal experiences, commitment to ethical principles, supportive work environment and teamwork, were associated with moral courage in nursing, contributing to a more comprehensive description of nurses' moral courage. Findings indicate that in nursing practice, there is a need for promoting multi-professional collaboration and discussion of ethical dilemmas to provide opportunities to enhance moral courage. Developing care environments in which hierarchy does not inhibit nurses' moral courage seems justified. Further research on moral courage with varying methodologies and multi-disciplinary and international approaches is needed.

Analysis of graduating nursing students' moral courage in six European countries

Background:

Moral courage is defined as courage to act according to one’s own ethical values and principles even at the risk of negative consequences for the individual. In a complex nursing practice, ethical considerations are integral. Moral courage is needed throughout nurses’ career.

Aim:

To analyse graduating nursing students’ moral courage and the factors associated with it in six European countries.

Research design:

A cross-sectional design, using a structured questionnaire, as part of a larger international ProCompNurse study. In the questionnaire, moral courage was assessed with a single question (visual analogue scale 0–100), the questionnaire also covered several background variables.

Participants and research context:

The sample comprised graduating nursing students (n = 1796) from all participating countries. To get a comprehensive view about graduating nursing students’ moral courage, the views of nurse managers (n = 538) and patients (n = 1327) from the same units in which the graduating nursing students practised were also explored, with parallel questionnaires.

Ethical considerations:

Ethical approvals and research permissions were obtained according to national standards in every country and all participants gave their informed consent.

Results:

The mean of graduating nursing students’ self-assessed moral courage was 77.8 (standard deviation 17.0; on a 0–100 scale), with statistically significant differences between countries. Higher moral courage was associated with many factors, especially the level of professional competence. The managers assessed the graduating nursing students’ moral courage lower (66.5; standard deviation 18.4) and the patients slightly higher (80.6; standard deviation 19.4) than the graduating nursing students themselves.

Discussion and conclusions:

In all countries, the graduating nursing students’ moral courage was assessed as rather high, with differences between countries and populations. These differences and associations between moral courage and ethics education require further research.

Investigation and Analysis of Undergraduate Nursing Students' Attitudes Toward Advanced Care Planning and Their Willingness to Implement

OBJECTIVE

The purpose of this study is to understand the attitude of undergraduate nursing students toward advanced care planning (ACP) and their willingness to implement ACP and to analyze its influencing factors, so as to provide evidence-based basis for life and death education and ACP-related training in colleges and universities.

METHODS

A total of 312 nursing undergraduates from a university in Chengdu (China) were surveyed by using general information questionnaire, attitude scale of ACP, and willingness questionnaire to implement ACP.

RESULTS

The scores of undergraduate nursing students' attitude toward ACP were 24.97 ± 2.75, and the scores of total willingness to ACP were 79.26 ± 9.70. Univariate analysis and multivariate linear regression analysis showed that religious belief, grade, family relationship, and family discussion of death were the factors influencing the willingness of nursing students to carry out ACP.

CONCLUSIONS

The attitude of undergraduate nursing students toward ACP tended to be positive, but their cognition of ACP was misunderstood, and their willingness to implement ACP needed to be improved. To improve the awareness and implementating willingness of undergraduate nursing students to ACP, it was recommended that colleges and universities carried out systematic standardized life and death education courses and ACP-related training.

Curriculum Redesign to Build the Moral Courage Values of Accelerated Bachelor's Degree Nursing Students

The increasing complexities of health care coupled with the decreasing importance of ethical values held by college students, including nursing students, compel nurse educators to step up efforts to strengthen the moral courage values of their students. While the nursing curriculum is the ideal breeding ground for building moral courage values, few studies describe how these values were embedded in any nursing curriculum, much less an accelerated bachelor's degree in nursing (ABSN) curriculum. This study outlines an ABSN curriculum with teaching-learning activities designed to build moral courage values in its classroom and clinical settings. Faculty perceptions of 29 ABSN students' honesty, respectfulness, responsibility, fairness, and compassion were surveyed 4 weeks after beginning, and again at the end of the ABSN program. The ABSN exit questionnaire administered annually by the College Office of Institutional Research, assessed the effectiveness of the ABSN curriculum. Of the 20 learning outcomes on the questionnaire, five related to moral courage values. The 5-point response scale ranged from Not at All, to Somewhat, Moderately, Well, and Extremely Well. t-test calculations revealed significant growth for four of the five values surveyed. Honesty, responsibility, fairness, and compassion were each positively significant at the p < .05 level. For the 27 of the 29 ABSN students who responded to the exit questionnaire, the Well and Extremely Well responses ranged from respectfulness and responsibility at 73%, to compassion and honesty at 78%, and fairness at 82%. Teaching-learning activities to build moral courage values successfully promoted the nursing program objective that the student will demonstrate proficient clinical, technological, and ethical competence in the delivery and management of health care.

Student courage: An essential for today's health education

AIM

The aim of this concept analysis is to propose the new concept of student courage as it operates within the context of healthcare professionals' education.

BACKGROUND

Nurses have a moral obligation that often requires courage. However, nursing students do not have the capacity to act with moral courage until they are close to licensure. Student courage is propositioned as a precursor to moral courage.

DESIGN

The Walker and Avant approach is used to examine the attributes, antecedents, consequences, and empiric referents of student courage. Cases are provided to represent how student courage can be operationalized and to distinguish student courage from moral courage.

RESULTS

The analysis demonstrates that the concept of student courage has four critical attributes: (a) persistence, (b) bravery, (c) overcoming fear, and (d) self-advocacy. Positive and negative consequences are associated with student courage and include: (a) moral distress, (b) criticism, (c) empowerment, and (d) self-knowledge.

CONCLUSIONS

This concept analysis helps fill the gap for nursing students transitioning into a professional role as well as clarifying a nursing student's role in patient care.

Challenges to discussing palliative care with people experiencing homelessness: a qualitative study

OBJECTIVES

To explore the views and experiences of people who are homeless and those supporting them regarding conversations and approaches to palliative care SETTING: Data were collected between October 2015 and October 2016 in homeless hostels and day centres and with staff from primary and secondary healthcare providers and social care services from three London boroughs.

PARTICIPANTS

People experiencing homelessness (n=28), formerly homeless people (n=10), health and social care providers (n=48), hostel staff (n=30) and outreach staff (n=10). METHODS: In this qualitative descriptive study, participants were recruited to interviews and focus groups across three London boroughs. Views and experiences of end-of-life care were explored with people with personal experience of homelessness, health and social care professionals and hostel and outreach staff. Saturation was reached when no new themes emerged from discussions.

RESULTS

28 focus groups and 10 individual interviews were conducted. Participants highlighted that conversations exploring future care preferences and palliative care with people experiencing homelessness are rare. Themes identified as challenges to such conversations included attitudes to death; the recovery focused nature of services for people experiencing homelessness; uncertainty regarding prognosis and place of care; and fear of negative impact.

CONCLUSIONS

This research highlights the need for a different approach to supporting people who are homeless and are experiencing advanced ill health, one that incorporates uncertainty and promotes well-being, dignity and choice. We propose parallel planning and mapping as a way of working with uncertainty. We acknowledge that these approaches will not always be straightforward, nor will they be suitable for everyone, yet moving the focus of conversations about the future away from death and dying, towards the present and the future may facilitate conversations and enable the wishes of people who are homeless to be known and explored.