Health literacy: a new challenge for laboratory medicine

Poor health literacy and inappropriate test prescribing hamper the value of laboratory medicine. The disintermediation between test producers and interpreters may happen both in Point of Care Tests, where doctor mediation is provided, but laboratory expert supervision is not, and in Direct to Consumer Testing, where no medical mediation is provided at all. In these cases, the respect for patient's autonomy must not preclude the principles of non-maleficence (as an individual concern) and justice (as a societal concern), as wrong test interpretation can generate confusion, anxiety, inappropriate social behavior, useless medical examinations and considerable cost increase. Considering how different is patient ability to understand test results (if any) and handle any physical and psychological consequence, promoting health literacy and professional laboratory mediation become crucial professional priorities. The aims of this review are 1) to describe the importance of health literacy on laboratory test interpretation, medical advice and therapeutic compliance; 2) to discuss doctor-level, patient-level and caregiver-level educational interventions in light of the four principles of the value-based framework (personal value, technical value, allocative value and societal value). Based on these premises, the authors support the need to enhance health literacy in patients, help doctors improve the communication of results and validate commercial tests under the scrutiny of scientific community.

Factors contributing to the promotion of moral competence in nursing

Ethics is a foundational competency in healthcare inherent in everyday nursing practice. Therefore, the promotion of qualified nurses' and nursing students' moral competence is essential to ensure ethically high-quality and sustainable healthcare. The aim of this integrative literature review is to identify the factors contributing to the promotion of qualified nurses' and nursing students' moral competence. The review has been registered in PROSPERO (CRD42023386947) and reported according to the PRISMA guideline. Focusing on qualified nurses' and nursing students' moral competence, a literature search was undertaken in January 2023 in six scientific databases: CINAHL, Cochrane Library, PsycINFO, PubMed Medline, Scopus and Web of Science. Empirical studies written in English without time limitation were eligible for inclusion. A total of 29 full texts were retrieved and included out of 5233 citations. Quality appraisal was employed using Joanna Briggs Institute checklists and the Mixed Method Appraisal Tool. Data were analysed using inductive content analysis. Research about the factors contributing to the promotion of qualified nurses' and nursing students' moral competence is limited and mainly explored using descriptive research designs. The contributing factors were identified as comprising two main categories: (1) human factors, consisting of four categories: individual, social, managerial and professional factors, and ten sub-categories; and (2) structural factors, consisting of four categories: educational, environmental, organisational and societal factors, and eight sub-categories. This review provides knowledge about the factors contributing to the promotion of qualified nurses' and nursing students' moral competence for the use of researchers, nurse educators, managers, organisations and policymakers. More research about the contributing factors is needed using complex intervention, implementation and multiple methods designs to ensure ethically sustainable healthcare.

Use and impact of the ANA Code: a scoping review

Adherence to professional ethics in nursing is fundamental for high-quality ethical care. However, analysis of the use and impact of nurses' codes of ethics as a part of professional ethics is limited. To fill this gap in knowledge, the aim of our review was to describe the use and impact of the Code of Ethics for Nurses with Interpretive Statements published by the American Nurses Association as an example of one of the earliest and most extensive codes of ethics for nurses with their interpretative statements and constituting a strong basis for the International Council of Nurses' Code of Ethics for Nurses. We based our review on previous literature using a scoping review method. We included both non-scientific and scientific publications to provide an analysis of codes of ethics which can be utilized in development and revision of other nurses' codes of ethics. In the searches, we used CINAHL and PubMed databases limiting publications to texts with a connection to the Code of Ethics for Nurses published from January 2001 to November 2022 and written in English. Searches yielded 1739 references, from which 785 non-scientific and 71 scientific publications were included for analysis of the data. Although non-scientific and scientific publications addressed different number of categories, the results indicated that in the both groups the use and impact focused on professional ethics, nursing practice, and work environment and less on education, research, or social health issues. Nurses' ethical standards were not addressed in non-scientific publications, and clinical issues and leadership were not in focus in scientific publications. To increase evidence-based knowledge of the impact of codes of ethics additional research is needed. Good scientific conduct was followed.

Effectiveness of educational interventions in reducing the stigma of healthcare professionals and healthcare students towards mental illness: A systematic review and meta-analysis

AIM

To examine the effectiveness of educational interventions in reducing stigma among healthcare professionals and students towards people with mental illness.

DESIGN

A systematic review and meta-analysis of randomized controlled trials (RCTs) and cluster RCTs.

DATA SOURCES

Articles published from database inception to October 2023 were systematically searched from seven databases (CINAHL, Embase, ProQuest Dissertations and Theses Global, PsycINFO, PubMed, Scopus, Web of Science), following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

METHODS

Random-effect meta-analyses were conducted. Heterogeneity was evaluated using the I2 statistics and Cochran's Q chi-squared test. A quality appraisal conducted at the study level used the Cochrane risk of bias tool and an outcome-level quality assessment utilized the Grades of Recommendation, Assessment, Development and Evaluation Approach. Publication bias was assessed using the funnel plot.

RESULTS

Twenty-five articles were included in this review. Meta-analysis reported statistically significant medium and small effect sizes for attitudes towards mental illness and attitudes towards people with mental illness respectively, showing the association between educational interventions and improved attitudes among healthcare professionals and students. However, a statistically non-significant effect was reported for knowledge of mental illness. Subgroup analyses indicated that face-to-face and contact-based interventions were particularly effective at reducing stigma. Notably, single-session interventions were just as effective as multiple sessions, suggesting a potential for resource-efficient approaches.

CONCLUSION

Educational interventions demonstrate promise in fostering more positive attitudes towards mental health issues. Future research should aim to determine the long-term effects of these interventions and include patient feedback on the stigmatizing behaviours of healthcare professionals and students, to holistically evaluate the effect of interventions.

NO PATIENT OR PUBLIC CONTRIBUTION

This study is a secondary review and does not require relevant contributions from patients or the public. WHAT DOES THIS PAPER CONTRIBUTE TO THE WIDER GLOBAL CLINICAL COMMUNITY?: Face-to-face contact-based educational sessions have proven to be the most effective. Reinforcing learning may be achieved through a series of repeated single-session interventions.

Nurses' experiences of ethical challenges concerning thirst in dying patients in specialist palliative care: a qualitative study

AIM

To describe nurses' experiences of ethical challenges in relation to thirst in terminally ill patients in specialist palliative care units.

RESEARCH DESIGN

A qualitative, reflexive thematic design with an inductive analysis was used.

PARTICIPANTS AND RESEARCH CONTEXT

Eighteen qualitative interviews with nurses working in six different specialist palliative care units in different hospitals in Sweden were conducted. The interviews were transcribed verbatim and analysed with a reflexive thematic analysis.

RESULTS

This study identified four themes that reflect ethical challenges experienced by nurses in the palliative care regarding thirst: Harmful infusions interfere with peaceful dying; conflict between tradition and personal experience; What is the right intervention to quench thirst? and; Lack of standard procedures, competence and interest among team members.

CONCLUSION

Palliative care nurses experience a number ethical challenges in relation to thirst in dying patients. The main challenge is the provision of fluids to dying patients via artificial infusions, which nurses struggle with, as they do not want to interfere with a peaceful dying process.

Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

Embedding Nursing Ethics Within Teaching Strategies in Nurse Residency Programs

Exposing new nurses to theoretical teaching strategies that help them to navigate the ethical challenges in clinical practice is essential for retention and long-term job satisfaction. This article explores the rationale for teaching ethics content in nurse residency programs and ways to navigate ethical decision-making in the clinical setting. Examples of evidence-informed teaching strategies that enhance knowledge retention and reduce the gap between ethical theory and practice are included.

Digital ethical reflection in home nursing care: Nurse leaders' and nurses' experiences

BACKGROUND

Nurse leaders increasingly need effective tools that facilitate the prioritisation of ethics and help staff navigate ethical challenges and prevent moral distress. This study examined experiences with a new digital tool for ethical reflection, tailored to improve the capabilities of both leaders and employees in the context of municipal long-term care.

AIM

The aim was to explore the experiences of nurse leaders and nurses in using Digital Ethical Reflection as a tool for ethics work in home nursing care.

RESEARCH DESIGN

The study employed a qualitative design, incorporating individual and focus group interviews for data collection. Qualitative content analysis was used to analyse the data.

PARTICIPANTS AND RESEARCH CONTEXT

The participants comprised six nurse leaders and 13 nurses, representing six home care zones across two Norwegian municipalities.

ETHICAL CONSIDERATIONS

The study involved informed, voluntary participation and was approved by the Norwegian Agency for Shared Services in Education and Research.

FINDINGS

Four themes were developed: a constant walk on the edge between engagement and discouragement and lost in translation describe the process, while tuning in to the ethical dimension and navigating ethical uncertainties illuminate the experienced significance of Digital Ethical Reflection.

CONCLUSION

Success with Digital Ethical Reflection in home nursing care depends on clear leadership planning, nurses' understanding of the tool's purpose, and active use of digital registrations. Support from ethically interested nurses enhances overall engagement. Further research is needed to explore the potential of Digital Ethical Reflection as an additional tool in long-term care ethics work.

Ethical considerations in the prehospital treatment of out-of-hospital cardiac arrest: A multi-centre, qualitative study

BACKGROUND

Prehospital emergency physicians have to navigate complex decision-making in out-of-hospital cardiac arrest (OHCA) treatment that includes ethical considerations. This study explores Danish prehospital physicians' experiences of ethical issues influencing their decision-making during OHCA.

METHODS

We conducted a multisite ethnographic study. Through convenience sampling, we included 17 individual interviews with prehospital physicians and performed 22 structured observations on the actions of the prehospital personnel during OHCAs. We collected data during more than 800 observation hours in the Danish prehospital setting between December 2019 and April 2022. Data were analysed with thematic analysis.

RESULTS

All physicians experienced ethical considerations that influenced their decision-making in a complex interrelated process. We identified three overarching themes in the ethical considerations: Expectations towards patient prognosis and expectations from relatives, bystanders, and colleagues involved in the cardiac arrest; the values and beliefs of the physician and values and beliefs of others involved in the cardiac arrest treatment; and dilemmas encountered in decision-making such as conflicting values.

CONCLUSION

This extensive qualitative study provides an in-depth look at aspects of ethical considerations in decision-making in prehospital resuscitation and found aspects of ethical decision-making that could be harmful to both physicians and patients, such as difficulties in handling advance directives and potential unequal outcomes of the decision-making. The results call for multifaceted interventions on a wider societal level with a focus on advance care planning, education of patients and relatives, and interventions towards prehospital clinicians for a better understanding and awareness of ethical aspects of decision-making.

Training Ethical Competence in a World Growing Old: A Multimethod Ethical Round in Hospital and Residential Care Settings

Ethical challenges are traditionally described in a negative light, even though moral conflict can express the individual ability to perceive when something is not working and promote change. The true question, therefore, is not to how to silence moral conflict but how to educate it. Although the need for ethical support of health- and social-care professionals in elderly care is clearly perceived, there is no universal method for providing effective interventions. The authors hypothesize that adequate training sessions can help care professionals enhance this skill, once clear goals and specific educational techniques are set. This research tests the hypothesis on twenty care professionals working in acute and residential care settings for the elderly, building on the ethics round method. Mixed methods drawn from literature and the experience of educators were adapted to meet different educational goals. Moral issues can hardly be removed from a context characterized by increasing demand and decreasing resources, but they can be recognized and addressed with common efforts, a critical attitude, and a growth mindset. Enhancing these skills in qualified workers can help them accept the reality of work, release pressure, and identify common team goals. Introducing these skills before graduation can help future workers avoid unreal expectations and reduce frustration and early job quit rates.

Reflective based learning for nursing ethical competency during clinical practices

BACKGROUND

A combination of theoretical and practical approaches is required to learn and acquire ethical competencies in caring. Occasionally, reflection on practical action differs from theoretical learning. In the context of reflective learning, issues such as ethical values can be discussed since they evoke conflict among nursing students.

AIM

To identify ethical conflicts encountered by nursing students during clinical placements and to determine their cooperation strategies.

RESEARCH DESIGN

Qualitative study with a content analysis according to Elo and Kinglas framework.

PARTICIPANTS AND RESEARCH CONTEXT

Students enrolled in a nursing program at a Spanish university aged between 22 and 35, mainly women.

METHODOLOGY

The study includes 134 ethical reflections from nursing students in the last year of the nursing program, written during their clinical practices in a variety of learning environments. The research team analyzed the reflections using an inductive content analysis method.

ETHICAL CONSIDERATIONS

Ethical permission was obtained by the management center according to Law 3/2028, and all the participants accepted to participate through the informed consent form.

FINDINGS

Three main categories emerged from the analysis of the ethical reflections: (1) evaluation of professional performance and patient care; (2) the student as the protagonist of the dilemma; (3) student coping. Student dilemmas and concerns are related to ignorance, student-patient communication, mistakes made and self-confidence. Some situations conflict with the autonomy of patients and their rights, and can contribute to stressful situations for patients. Stress factors include hospital routines, which the patient cannot modify, and asymmetric relationships with staff, which encourage passivity.

CONCLUSION

All ethical problems detected by the students begin with the professional-patient relationship, including issues related to bad news, errors or malpractice. Reflection on the ethical values of nursing, both in the classroom and in clinical practices, allows students to develop a greater ethical awareness of care, enhancing their decision-making skills in ethical dilemmas.

Developing and Testing Digital Ethical Reflection in Long-Term Care: Nurses' Experiences

Introduction

Nurses working in municipal long-term care face ethical challenges that can lead to moral distress and discomfort for the nurse and affect the quality of patient care. Tools and methods that contribute to increased ethical awareness and support for nurses dealing with moral issues are lacking. Technological innovations may be suitable for ethics work, but little research has been conducted on how such solutions could be designed or their potential benefit. Therefore, this study contributes knowledge about the development and testing of a digital tool for ethics support among nurses.

Objective

To investigate how digital ethical reflection can support ethics work among nurses working in long-term care.

Methods

A digital ethical reflection tool was designed and tested in nursing homes and home nursing care in collaboration with two Norwegian municipalities. The study used sequential explanatory mixed-methods design. Over a 6-week period, at the end of each shift, nurses digitally reported the ethical challenges they had experienced. Their responses and experiences were described using descriptive statistics. Additionally, focus group interviews were conducted and analyzed using reflexive thematic analysis (TA).

Results

During the study period, 17 nurses reported a total of 223 registrations, with 24.8% stating that they had been in an ethically difficult situation. The digital reporting was perceived as practically applicable and helped to increase nurses' awareness of morally charged situations. The value of the registrations was found to depend on manager participation and the application of the obtained information. The participating nurses become aware that they lacked an arena for meaningful dialogue with and recognition from their manager.

Conclusions

Information obtained through digital reflection can form the basis for ethical reflections at the departmental level. Digital reflection has the potential to become a tool for managers in their support for employees facing ethical challenges when providing long-term care.

Research, education, ethics consultation: evaluating a Bioethics Unit in an Oncological Research Hospital

BACKGROUND

This study aims to quantitatively and qualitatively evaluate the activities of a Bioethics Unit (BU) 5 years since its implementation (2016-2020). The BU is a research unit providing empirical research on ethical issues related to clinical practice, clinical ethics consultation, and ethical education for health care professionals (HPS).

METHODS

We performed an explanatory, sequential, mixed-method, observational study, using the subsequent qualitative data to explain the initial quantitative findings. Quantitative data were collected from an internal database and analyzed by descriptive analysis. Qualitative evaluation was performed by semi-structured interviews with 18 HPs who were differently involved in the BU's activities and analyzed by framework analysis.

RESULTS

Quantitative results showed an extensive increment of the number of BU research projects over the years and the number of work collaborations with other units and wards. Qualitative findings revealed four main themes, concerning: 1. the reasons for contacting the BU and the type of collaboration; 2. the role of the bioethicist; 3. the impact of BU activities on HPs, in terms of developing deeper and more mature thinking; 4. the need to extend ethics support to other settings. Overall, our results showed that performing both empirical bioethics research and more traditional clinical ethics activities at the same unit would produce an impetus to increase collaboration and spread an 'ethical culture' among local HPs.

CONCLUSIONS

Our findings contribute to a growing body of literature on the models of clinical ethics support services and the role of empirical research in bioethics internationally. They also prepare the ground for the implementation of a multidisciplinary Clinical Ethics Committee (CEC) that aims to support the BU's ethics consultation service within the local context.

The effects of an ethics laboratory program on moral sensitivity and professional values in nursing students: A randomized controlled study

BACKGROUND

Recently, moral sensitivity and professional values have become increasingly important in nursing education and have been tried to be improved.

OBJECTIVES

To investigate the effects of an ethics laboratory program integrated with the fundamentals of nursing course on the moral sensitivity and professional values of nursing students.

DESIGN

The present study was designed as a randomized controlled study. The 8-week ethics laboratory program was applied to the students in the intervention group. In the ethics laboratory program, interactive education methods, such as ethical scenarios, case studies, roleplay, group discussions, project papers and watching movies, were applied. Control group received the standard fundamentals of nursing curriculum.

PARTICIPANTS

The sample size was determined using stratified block randomization method, and 100 nursing students were assigned to intervention (n = 50) and control group (n = 50).

RESULTS

There was no baseline difference between the groups. The moral sensitivity average of the students in the intervention (82.66 ± 12.57) was lower than the average of the control group (85.64 ± 16.83) after the ethics laboratory program; however, the difference was not statistically significant (p > .05). Similarly, there were no significant differences between the intervention (132.32 ± 16.83) and the control group (131.81 ± 20.55) regarding the average score of professional values. In the responsibility sub-dimension of professional values, there was a statistically significant increase in the intervention group (p < .05).

CONCLUSION

The findings suggest that the ethics laboratory program for nursing students is effective in promoting responsibility sub-dimension of professional values. However, there was no significant effect on students' moral sensitivity and other dimensions of professional values. Further refinements of interventional research in ethics education and measurement of learning outcomes should be developed.

The usability, feasibility and fidelity of the Ethics Quarter e-learning intervention for nurse managers

BACKGROUND

Nurse managers (NMs) expect support to carry out their ethical activities in a complex health care environment. In this study, the Ethics Quarter (EQ) is suggested as a new educational ethics e-learning intervention for nurse managers. The aim of this study was to evaluate the usability, feasibility and fidelity of the EQ. The goal was to create a new way to support NMs' ethical activity profile (developing one's own ethics knowledge, influencing ethical issues, conducting or implementing ethics research, identifying and solving ethical problems) for the use of healthcare organizations.

METHODS

The EQ was developed under guidance of the criteria for complex interventions in health care (CReDECI2) guideline. A cross-sectional survey was conducted within the intervention group after a randomized controlled trial (the main study is registered in ClinicalTrials.gov with the identifier: 04234503). The participants were NM members of the Union of Health and Social Care Professionals in Finland (n = 95).

RESULTS

A system usability scale (SUS) assessed the overall usability of EQ as good (a mean SUS score of 85.40 out of 100). Positive feedback about the EQ's feasibility was reported in structured and open questions (a good, necessary and practical research knowledge-based e-learning intervention for all nurse managers) and recommendations for further development (intervention contents could be even more challenging and interactive) were highlighted. Fidelity, measured with Google Analytics, reported shorter time used by NMs on the EQ education than estimated.

CONCLUSIONS

The findings support the high usability, feasibility and average fidelity of the EQ intervention and its potential while also providing evidence for the development of future ethics education. Health care organizations would benefit from adopting the EQ to support the ethical activities and ethical activity profile of NMs. Additionally, this study provides an example of ethics intervention development and evaluation in nursing research.

The relationship between moral sensitivity and professional values and ethical decision-making in nursing students

BACKGROUND

More researchers have paid attention to the ethical decision-making in nursing worldwidely due to the increasing complexity of ethical issues and dilemmas. Ethical decision-making ability is regarded as one of the core competences of nursing practice and has the potential to resolve ethical issues. It is important to identify the key variables related to ethical decision-making and understand their relationship between them respectively. It is also helpful to design interventions to promote nursing students' ability to resolve ethical dilemmas.

OBJECTIVE

This study aims to examine the relationship between moral sensitivity, professional values and ethical decision-making respectively, and to explore whether professional values have mediating effect on the relationship between moral sensitivity and ethical decision-making among nursing undergraduates in Chinese nursing education context.

DESIGN

This study is a cross-sectional descriptive correlational design.

METHODS

263 nursing undergraduates from Nursing and Health School, Zhengzhou University in Henan province of China participated in the study and received the investigation. Their ethical decision-making, moral sensitivity and professional values were measured through the following three questionnaires, including the Judgement About Nursing Decision (JAND), Chinese Moral Sensitivity Questionnaire-Revised Version (MSQ-R-CV) and Chinese Nurses' Professional Values Scale-Revised Version (NPVS-R-CV). The data were processed and analysed by SPSS 23.0 and AMOS 24.0. The statistical methods included descriptive statistics, independent-samples t-tests, one-way analysis of variance, Pearson's correlation analyses and structural equation modeling.

RESULTS

Moral sensitivity is positively correlated with ethical decision-making (P < 0.01). Professional values is positively correlated with ethical decision-making (P < 0.01) and also has a mediating effect on the relationship between moral sensitivity and ethical decision-making (P < 0.01).

CONCLUSION

The investigation contributes to a broader understanding of the factors that influence nursing students' ethical decision-making. Developing ethics education around nursing students' professional values and moral sensitivity can improve their ethical decision-making ability.

Midwifery students' experiences of support for ethical competence

Background:

Midwifery students are confronted with several ethical dilemmas and challenging situations during clinical midwifery care practice. Since ethical competence of midwifery students is under development, it is important to support the students’ learning progress of ethical issues from diverse viewpoints.

Objective:

From the perspective of didactics of caring science and the context of midwifery students, to explore how midwifery students’ experience supports for ethical competence in midwifery education and investigate how ethically challenging situations have been carried out during clinical midwifery care practice.

Design:

Qualitative, explorative and descriptive design with inductive nature.

Methods:

Focus group interviews with nine Swedish midwifery students. Hans-Georg Gadamer’s philosophical hermeneutics was applied to guide the interpretation.

Ethical considerations:

Ethical principles and scientific guidelines were followed. Informed consent was obtained from the participants. Confidentiality was respected and quotations anonymised.

Results:

Receiving support when ethically challenging situations occur in clinical midwifery practice is important and necessary. One main theme, such as support is a human and caring factor in the midwifery students’ Bildung process on ethical competence, and four subthemes, such as supporting through trust and responsibility; supporting through dignity and respect; supporting through truthfulness and justice; and supporting through dialogue and reflection, were created from the hermeneutical interpretation.

Discussion:

Teaching ethics should be carefully planned, consistent and continue throughout the midwifery education. There is dispersion in the pedagogy of ethical situations, the methods and perceptions associated with it, and in obtaining possible support for students. Developing well-experienced methods could benefit the support of midwifery students’ ethical competence when they experience ethically challenging situations in midwifery care practice.

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.

The effectiveness of the Ethics Quarter intervention on the ethical activity profile of nurse managers: A randomized controlled trial

AIM

To test the effectiveness of a new ethics educational e-learning intervention, Ethics Quarter, in supporting nurse managers' ethical activity profile.

BACKGROUND

Health care organisations need evidence-based ethics interventions to support nurse managers' ethical activity profile.

METHODS

A parallel-group, individually randomized controlled trial was conducted in 2020. Finnish nurse managers nationwide [members of the Union of Health and Social Care Professionals in Finland (Tehy) trade union] were randomly allocated to intervention (n = 169) or control group (n = 172). The intervention group participated in the Ethics Quarter comprising twelve 15-min evidence-based educational 'quarters' spread over 6 weeks. The control group had standard organisational ethics structures. The primary and secondary outcomes were ethical activity profile and ethics knowledge, respectively. The Consolidated Standards of Reporting Trials (CONSORT) statement for study design and reporting was adopted.

RESULTS

Ethical activity profile showed statistically significant differences in mean changes between the groups from baseline to 10 weeks: all five dimensions were statistically significantly higher in the intervention group compared with the control group (p = <.0001).

CONCLUSION

The Ethics Quarter was effective in increasing nurse managers' ethical activity profile.

IMPLICATIONS FOR NURSING MANAGEMENT

Applying this ethics educational e-learning intervention would benefit nursing management education and health care organisations.

TRIAL REGISTRATION

clinicaltrials.gov: NCT04234503.

Moral Resilience for Critical Care Nurses

Ethically challenging situations are an increasing phenomenon in the nurse's environment, and literature on the subject is growing. Morally challenging experiences common in the critical care environment include end-of-life situations, barriers to providing the best care possible, and lack of organizational resources. These experiences can lead to moral distress and subsequent negative impacts on the clinician. Emerging in the literature are strategies to address the impact of moral distress through the development of moral resilience. Moral resilience is gained through personal commitment and organizational support.

Nurses Who Assume the Role of Advocate for Older Hospitalized Patients: A Qualitative Study

INTRODUCTION

Patient advocacy, acting on behalf of patients' unmet needs, is fundamental to nursing, and the perception of the need for advocacy motivated this study. Nurses experience moral discomfort, which results from a divergent view regarding medical or caregivers' decisions about patients' clinical proceedings, in which patients' involvement in making those decisions is either doubtful or absent.

OBJECTIVES

The aim of this study is to assess the need for advocacy and explore the perspectives of nurses engaged in the care of older patients.

METHODS

The methodological orientation is that of a qualitative design, by using a purposive and criterion sampling. The sample was of 14 nurses of a ward of general medicine. Focus group as collecting data tool was used, followed by a thematic analysis.

RESULTS

Nurses demonstrated a high level of moral sensitivity to ethical problems in clinical practice and on occasions, the courage to bring the problem to the physicians or patients' family's attention, or help patients develop self-determination. However, it is difficult to advocate because of insufficient communication between professionals, insufficient knowledge of ethics, and the emotional burden it places on nurses which results in emotional resignation in the face of interprofessional teams' lack of consideration of nurses' opinions.

CONCLUSION

This research highlighted nurses' need for advocacy to promote patients' rights, wishes, and values. It is essential for nurses to be aware of their level of moral sensitivity and develop a strategy to regain courage to engage in advocacy. Therefore, ethics education and interprofessional ethical leadership is desired, which inspires healthcare professionals' work and allows the foundations of an ethical decisionmaking process to be laid through patients and their families' active involvement.

The development of moral sensitivity of nursing students: A scoping review

Moral sensitivity is known to be the starting point for moral competence and even is a core concept in the curricula for bachelor's-level nursing students in the Netherlands. While the development of moral sensitivity in nursing is commonly agreed to be important, there is no clear understanding of how to develop moral sensitivity through nursing education and what components of nursing education contribute to moral sensitivity. Studies on educational interventions could build knowledge about what works in developing moral sensitivity and how to achieve this outcome. Therefore, the aim of this study is to explore if and how educational interventions contribute to the development of moral sensitivity in nursing students. A scoping review was conducted. Four electronic databases were searched: CINAHL, PubMed, MEDLINE and SpringerLink. Articles that were not about formal or initial nursing education and that had no link to moral development or moral sensitivity were excluded. After the final selection on educational interventions, 10 articles out of the initial 964 resources were included in the review. Three different but related dimensions of moral sensitivity emerged from the literature: (1) raising moral awareness, (2) providing the ability to frame and name ethical issues and (3) improving moral reasoning ability. Half of the studies used quantitative measures to evaluate the educational intervention, in particular the Moral Sensitivity Questionnaire; the other half used diverse qualitative evaluation methods. None of the studies presented teaching methods that included all three dimensions of moral sensitivity. Moral awareness of self appears to be more loosely connected to the other two dimensions, which raises the question of whether it can be seen as a prerequisite for them. To encompass all dimensions of moral sensitivity, a mix of quantitative and qualitative measures seems most appropriate to study that topic.

Self-evaluated ethical competence of a practicing physiotherapist: a national study in Finland

Background

Patients have the right to equal, respectful treatment. Nowadays, one third of patient complaints concern health care staff’s behavior towards patients. Ethically safe care requires ethical competence, which has been addressed as a core competence in physiotherapy. It has been defined in terms of character strength, ethical awareness, moral judgment skills in decision-making, and willingness to do good. The purpose of this study was to analyze the ethical competence of practicing physiotherapists.

Method

A self-evaluation instrument (Physiotherapist’s Ethical Competence Evaluation Tool) based on an analysis of a concept “ethical competence” was constructed in 2016 and physiotherapists (n = 839), working in public health services or private practice responded to the questionnaire.

Results

Based on the results, most of the physiotherapists evaluated themselves highly ethically competent in all areas of ethical competence, subscales being Strength, Awareness, Skills and Will. Willingness to do good was evaluated as highest, while character strength, including the strength to support ethical processes and speak on behalf of the patient, was evaluated the lowest. Physiotherapists most commonly consult a colleague when encountering an ethical problem. Other methods for problem solving are not very familiar, neither are the international or national ethical codes of conduct.

Conclusions

This was the first attempt to assess all aspects of ethical competence empirically in a clinical environment in physiotherapy, using a novel self-evaluation instrument. Even if physiotherapists evaluate themselves as competent in ethics, further exploration is needed for ethical awareness. Also the patients’ viewpoints about ethically competent care should be considered, to better ensure ethical safety of the patient.

Patient's informational privacy in prehospital emergency care: Paramedics' perspective

BACKGROUND

As a fundamental human right in healthcare, informational privacy creates the foundation for patient's safety and the quality of care. However, its realization can be a challenge in prehospital emergency care, considering the nature of the work.

OBJECTIVES

To describe patient's informational privacy, its realization, and the factors related to the realization in prehospital emergency care from the perspective of paramedics.

RESEARCH DESIGN

A descriptive questionnaire study was conducted. The data were analyzed with inductive content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

The participants (n = 26) were paramedics in one of the 22 rescue departments in Finland.

ETHICAL CONSIDERATIONS

The study received ethical approval from the ethics committee of the University of Turku (Finland). Permission for the study was given by the collaborating rescue department.

FINDINGS

Paramedics described patient's informational privacy as patients' right to their own health records, as protection of the patient's health records, and as comprehensive respect of the patient's privacy by the persons involved in the patient's care. In general, informational privacy was described as being realized regarding confidentiality, reporting, and maintaining the patient's health records. However, it was also described as being dependent on the context, and some areas in need of improvement were identified. Promoting and preventing factors related to the realization were also identified. The promoting factors were paramedics' professional activity, environment, training, and guidelines. The preventing factors were the nature of the work, paramedics' attitudes, and the lack of knowledge concerning informational privacy among paramedics, the collaborating authority, patients, and relatives.

DISCUSSION AND CONCLUSION

Paramedics had a multidimensional understanding of informational privacy and the factors related to its realization. However, its realization varies, and more research and education are therefore needed to enhance the realization and to provide equal and high-quality care for all the patients in prehospital emergency care.

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.