Ethical conflicts in patient relationships: Experiences of ambulance nursing students

Moral sensitivity as a personal and work attribute of emergency care nurses: a cross-sectional study

OBJECTIVE

to analyze the moral sensitivity of Brazilian emergency care nurses according to their personal and work characteristics.

METHOD

this is a quantitative, descriptive, cross-sectional study with a convenience sample. A total of 422 nurses from emergency care services in the five regions of Brazil took part. Sociodemographic and work-related information was collected, as well as the Brazilian version of the Moral Sensitivity Questionnaire. After approval by the Research Ethics Committee, the data was collected using a self-administered form on the Google Forms Platform, organized using Excel software and analyzed using the R language.

RESULTS

nurses with longer experience in emergency care services showed higher levels in the interpersonal orientation, moral conflict and moral significance dimensions, while in the professional knowledge dimension, men showed higher levels, as evidenced by items that include confidence in nursing knowledge, intuition, experience and opinion.

CONCLUSION

the differences in the nurses' moral sensitivity were due to their professional experience. It should be emphasized that valuing the sharing of intergenerational experiences in service could be a possible strategy for fostering moral competencies in the field of practice.

Self-determination in older patients: Experiences from nurse-dominated ambulance services

AIM

To describe ambulance clinicians' experiences of self-determination in older patients.

DESIGN

The study had an inductive and explorative design, guided from a life-world perspective.

METHODS

Thirty-two Swedish ambulance clinicians were interviewed in six focus groups in November 2019. The data were analysed with content analysis, developing manifest categories and latent themes.

FINDINGS

The ambulance clinicians assessed the older patients' exercise of self-determination by engaging in conversation and by being visually alert, to eventually gain an overall picture of their decision-making capacity. This assessment was used as a platform when informing older patients of their rights, thus promoting their participation in care. Having limited time and narrow guidelines counteracted ambulance clinicians' ambitions to support older patients' general desire to avoid hospitalization, which resulted in an urge to displace their responsibility to external decision-makers.

CONCLUSION

Expectations that older patients with impaired decision-making ability will give homogeneous responses mean an increased risk of ageist attitudes with a simplified view of patient autonomy. Such attitudes risk the withholding of information about options that healthcare professionals do not wish older patients to choose. When decision-making is difficult, requests for expanded guidelines may paradoxically risk alienation from the professional nursing role.

IMPLICATIONS AND IMPACT

The findings show ambulance clinicians' unwillingness to shoulder their professional responsibility when encountering older patients with impaired decision-making ability. In assuming that all older patients reason in the same way, ambulance clinicians tend to adopt a simplistic and somewhat ageist approach when it comes to patient autonomy. This points to deficiencies in ethical competence, which is why increased ethics support is deemed suitable to promote and develop ethical competence. Such support can increase the ability to act as autonomous professionals in accordance with professional ethical codes.

REPORTING METHOD

This study adhered to COREQ guidelines.

PATIENT AND PUBLIC CONTRIBUTION

None.

Ambulance clinicians' understanding of older patients' self-determination: A vignette study

BACKGROUND

Older patients are often vulnerable and highly dependent on healthcare professionals' assessment in the event of acute illness. In the context of ambulance services, this poses challenges as the assessment is normally conducted with a focus on identifying life-threatening conditions. Such assessment is not fully satisfactory in a patient relationship that also aims to promote and protect patient autonomy.

AIM

To describe ambulance clinicians' understanding of older patients' self-determination when the patient's decision-making ability is impaired.

RESEARCH DESIGN

A qualitative design with an inductive approach, guided by descriptive phenomenology.

PARTICIPANTS

In total, 30 ambulance clinicians, comprised of 25 prehospital emergency nurses, 1 nurse and 4 emergency medical technicians participated in 15 dyadic interviews.

ETHICAL CONSIDERATIONS

The research was conducted in accordance with the Declaration of Helsinki, and permission was granted by the Swedish Ethical Review Authority.

FINDINGS

The findings are presented in two themes: (1) Movement between explicit and implicit will; and (2) Contradictions about the patient's best interests. The clinicians' interpretations are based on an understanding of the patient's situation using substitute decision-making in emergency situations and conversations that reveal the patient's explicit wishes. Sometimes the clinicians collaborate to validate the patient's implicit will, while they at other times subordinate themselves to others' opinions. The clinicians find themselves in conflict between personal values and organisational values as they try to protect the patient's self-determination.

CONCLUSION

The results indicate that older patients with an impaired decision-making ability risk losing the right to self-determination in the context of ambulance services. The clinicians face challenges that significantly affect their ability to handle the older patient's unique needs based on a holistic perspective and their ability to be autonomous.

Ethics rounds in the ambulance service: a qualitative evaluation

BACKGROUND

It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds.

METHODS

This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis.

RESULTS

Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue.

CONCLUSION

Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.

Older patients' perceptions of the Swedish ambulance service: A qualitative exploratory study

BACKGROUND

As worldwide life expectancy increases, the Swedish Ambulance Service is likely to be affected by the demographic shift towards a larger proportion of older persons. An older population tends to increase the demand for ambulances, indicating a need to illuminate older patients' perspective. Thus, the aim of this study was to explore older patients' perceptions of the Swedish Ambulance Service.

METHODS

This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg.

RESULTS

Three main descriptive categories emerged to describe the underlying conceptions in the interviews; A double-edged encounter, Trust is created by perceived competence, and Safety through accessibility in vulnerable situations.

CONCLUSION

Older patients described trust in ambulance clinicians as a prerequisite for feeling safe enough to share their feelings and allow a bodily examination. However, they also criticized the care provided because they questioned the need for certain actions.

The effect and comparison of training in ethical decision-making through lectures and group discussions on moral reasoning, moral distress and moral sensitivity in nurses: a clinical randomized controlled trial

BACKGROUND

Ethical decision‑making and behavior of nurses are major factors that can affect the quality of nursing care. Moral development of nurses to making better ethical decision-making is an essential element for managing the care process. The main aim of this study was to examine and comparison the effect of training in ethical decision-making through lectures and group discussions on nurses' moral reasoning, moral distress and moral sensitivity.

METHODS

In this randomized clinical trial study with a pre- and post-test design, 66 nurses with moral reasoning scores lower than the average of the community were randomly assigned into three equal groups (n = 22) including two experimental groups and one control group. Ethical decision-making training to experimental groups was provided through the lectures and group discussions. While, the control group did not receive any training. Data were collected using sociodemographic questionnaire, the nursing dilemma test (NDT), the moral distress scale (MDS) and the moral sensitivity questionnaire (MSQ). Unadjusted and adjusted binary logistic regression analysis was reported using the odds ratio (OR) and 95% confidence intervals.

RESULTS

Adjusted regression analysis showed that the probability of increasing the nursing principle thinking (NPT) score through discussion training was significantly higher than lecture (OR: 13.078, 95% CI: 3.238-15.954, P = 0.008), as well as lecture (OR: 14.329, 95% CI: 16.171-2.005, P < 0.001) and discussion groups compared to the control group (OR: 18.01, 95% CI: 22.15-5.834, P < 0.001). The possibility of increasing moral sensitivity score through discussion training was significantly higher than lecture (OR: 10.874, 95%CI: 6.043-12.886, P = 0.005) and control group (OR: 13.077, 95%CI: 8.454-16.774, P = 0.002). Moreover, the moral distress score was significantly reduced only in the trained group compared to the control, and no significant difference was observed between the experimental groups; lecture group vs. control group (OR: 0.105, 95% CI: 0.015-0.717, P = 0.021) and discussion group vs. control group (OR: 0.089, 95% CI: 0.015-0.547, P = 0.009).

CONCLUSIONS

The results of this study indicate that ethical decision-making training is effective on empowerment of ethical reasoning. Whereas the group discussion was also effective on increasing the ethical sensitivity, it is recommended the training plan provided in this study to be held as workshop for all nurses in health and treatment centers and placed in curricular plan of nursing students.

REGISTRATION

This randomized clinical trial was registered in Iranian Registry of Clinical Trials under code (IRCT2015122116163N5) in 02/07/2016.

The ways specialist nursing students understand the work in the ambulance service - a national Swedish phenomenographic study

Objective

Design, sample, and measurements

Findings

Conclusions

Paramedics' perceptions of job demands and resources in Finnish emergency medical services: a qualitative study

BACKGROUND

Paramedics' fatigue is rising. Stress factors show increased risk for burnout, fatigue, leaving the profession, decreased performance and risk for patient safety. Meanwhile, paramedics' strong community of practice, autonomy and a sense of professional respect are important factors in forming psychological resilience. We aimed to explore Finnish paramedics' perceptions of job demands and resources.

METHODS

Our study design was descriptive, inductive with a constructivist approach. Using reflexive thematic analysis, we analyse open-ended questions, from a web-based survey and essays written by Finnish paramedic masters-degree students. The study followed the SRQR checklist.

RESULTS

We identified paramedics' job demands as stress from a high workload, environmental factors and emotional burden. Performance expectations and a sense of inadequacy were further noted, as well as an organizational culture of hardiness, presenting lack of support and sense of inequality. Paramedics' job resources were pressure management strategies, which were expressed as positive coping mechanisms, agency to affect workload and professional self-actualization, expressed as psychologically safe work community, professional pride and internal drive to professional development.

CONCLUSIONS

Finnish paramedics exhibit resources and demands related to uncertainty and emotional burden as well as cultural hardiness and psychological safety in communities.

PATIENT OR PUBLIC CONTRIBUTION

This study was done based on survey data collected and analysed by the authors. No patient or public contribution was utilized for this study.

Correlation between self-awareness, communication ability and caring ability of undergraduate nursing students/A cross-sectional study

BACKGROUND

Caring ability is the core ability of nursing. Here we explored the factors affecting the caring ability of undergraduate nursing students. Self-awareness and communication ability are potential variables to improve caring ability.

OBJECTIVE

To explore the relationship between self-awareness, communication ability and caring ability of domestic undergraduate nursing students and to explore whether communication ability has an intermediary effect between self-awareness and caring ability.

DESIGN

A descriptive cross-sectional study using an online questionnaire.

SETTING AND PARTICIPANTS

Undergraduate nursing students (n = 1411) who attended Dalian Medical University, Liaoning, China. Participants were recruited through convenience and snowball sampling methods using online platforms.

METHODS

The questionnaire used the Self-Consciousness Scale, Clinical Communication Competence Evaluation Scale and Caring Ability Inventory. The data were processed and analyzed by SPSS 24.0 and Amos 23.0. Descriptive statistics, Pearson correlation analysis and structural equation modeling were performed for data analysis.

RESULTS

There was a significant positive correlation between undergraduate nursing students' caring ability and their self-awareness and communication ability (p < 0.001). Communication ability played a partial mediating role between self-awareness and caring ability (p < 0.001), and the mediating effect was 34.2 %.

CONCLUSIONS

The self-awareness of undergraduate nursing students directly affects their caring ability and can also indirectly affect their caring ability through their communication ability. Educators can guide and cultivate student self-awareness and communication ability and promote self-regulation, so as to improve students' caring ability and improve clinical development.

Older patients' autonomy when cared for at emergency departments

Background

Older patients in emergency care often have complex needs and may have limited ability to make their voices heard. Hence, there are ethical challenges for healthcare professionals in establishing a trustful relationship to determine the patient’s preferences and then decide and act based on these preferences. With this comes further challenges regarding how the patient’s autonomy can be protected and promoted.

Aim

To describe nurses’ experiences of dealing with older patients’ autonomy when cared for in emergency departments (EDs).

Research design

This study adopted reflective lifeworld theory and a phenomenological design.

Participants and research context

A total of 13 open-ended interviews were performed with nurses working at two EDs in Sweden.

Ethical considerations

The study was reviewed by the Ethical Advisory Board in South East Sweden and conducted according to the Declaration of Helsinki. All participants gave consent.

Findings

Nurses’ experiences of dealing with older patients’ autonomy in EDs are characterized by moving in a conflicting uphill struggle, indicating obscure thoughts on how patient autonomy can be protected in an ethically challenging context. The phenomenon is further described with its meaning constituents: ‘Being hampered by prioritization under stress’, ‘Balancing paternalism and patient autonomy’, ‘Making decisions without consent in the patient’s best interests’ and ‘Being trapped by notions of legitimate care needs’.

Conclusion

Stressful work conditions and lacking organizational strategies in EDs contribute to nurses maintaining unjustified paternalistic care, regardless of the patient’s ability and medical condition, and questioning who has legitimacy for participating in decisions about care. The nurses’ protection and promotion of older patients’ autonomy is dependent on the opportunity, ability and willingness to create a patient relationship where the patient’s voice and preferences are valued as important. Consequently, strategies are needed to improve patient autonomy in EDs based on the idea of ‘relational autonomy’.

Identifying and mapping professional identities among Swedish ambulance nurses: A multiple qualitative case study

Research on ambulance culture and identity is globally scant and nonexistent within a Swedish context. This study on Swedish ambulance nurses serves as a first step and an important entry point into this topic. The purpose was to describe professional ambulance identities among four participants who had served between several years and decades in the ambulance services. Qualitative data was obtained through initial in-depth interviews and follow-up data gathering at a later stage. The theoretical underpinnings adhered to both narrative psychology and dialogical self theory, strengthening the capacity to develop new knowledge about professional identities. The findings present four distinct types of identities among the participants. Individuality and diversity amongst the development of core identities is shown to be cultivated by the dialogue between professional and personal identities. This dialogical process began at a stage in the ambulance career when the strict demarcation line between professional and personal identities was crossed.

Nurses' experiences of encountering patients with mental illness in prehospital emergency care - a qualitative interview study

BACKGROUND

Nurses working in prehospital emergency care (PEC) encounter patients with all types of health conditions. Increasingly, they are encountering patients suffering from mental illness and this trend reflects the worldwide increase in mental illness. There is very little current knowledge of encounters between nurses and patients with mental illness in 'PEC', especially from the nurses' perspectives.

AIM

The aim of the study is to investigate nurses' experiences of encountering patients with mental illness in 'PEC'.

METHODS

The participants were recruited in a region in southeast Sweden (that covers approximately 5600 km2 and has 300,000 inhabitants). In total, 17 nurses consented to participate. The participants were asked to narrate their individual experience of encountering patients with mental illness. The interviews were transcribed verbatim, then analysed with qualitative content analysis.

RESULTS

The result is presented in terms of three themes and eight sub-themes. The main themes are 'Lacking trust in the patient and one's own abilities', 'Being under internal and external influences' and 'Moving towards a genuine nurse-patient relationship'.

CONCLUSION

The results show that nurses strive to lay the foundation for a trusting relationship. Simultaneously nurses encountering is characterized by a mistrust and it is influenced by pre-understanding and emotions when they take care for patients. The findings could be used to develop nurses' readiness and capability to encounter patients with mental illness and to respond appropriately to the patients somatic and mental care needs.

Ethics education to support ethical competence learning in healthcare: an integrative systematic review

BACKGROUND

Ethical problems in everyday healthcare work emerge for many reasons and constitute threats to ethical values. If these threats are not managed appropriately, there is a risk that the patient may be inflicted with moral harm or injury, while healthcare professionals are at risk of feeling moral distress. Therefore, it is essential to support the learning and development of ethical competencies among healthcare professionals and students. The aim of this study was to explore the available literature regarding ethics education that promotes ethical competence learning for healthcare professionals and students undergoing training in healthcare professions.

METHODS

In this integrative systematic review, literature was searched within the PubMed, CINAHL, and PsycInfo databases using the search terms 'health personnel', 'students', 'ethics', 'moral', 'simulation', and 'teaching'. In total, 40 articles were selected for review. These articles included professionals from various healthcare professions and students who trained in these professions as subjects. The articles described participation in various forms of ethics education. Data were extracted and synthesised using thematic analysis.

RESULTS

The review identified the need for support to make ethical competence learning possible, which in the long run was considered to promote the ability to manage ethical problems. Ethical competence learning was found to be helpful to healthcare professionals and students in drawing attention to ethical problems that they were not previously aware of. Dealing with ethical problems is primarily about reasoning about what is right and in the patient's best interests, along with making decisions about what needs to be done in a specific situation.

CONCLUSIONS

The review identified different designs and course content for ethics education to support ethical competence learning. The findings could be used to develop healthcare professionals' and students' readiness and capabilities to recognise as well as to respond appropriately to ethically problematic work situations.

Nurse preceptors' experience-based strategies for supporting learning in the ambulance service-A combined focus group and dyadic interview study

Ambulance service organizations worldwide report about an expanding professional role, responsibilities and scope of practice for ambulance clinicians, resulting in discussions concerning educational design and desired professional competencies. To face the contemporary demands in ambulance care, non-technical skills are advocated and clinical practice considered fundamental for the development of these abilities. However, there is very little research concerning educational strategies for supporting the desired competencies for novice registered nurses in the ambulance service.

AIM

To describe and explore nurse preceptors' experience-based strategies for supporting registered nurses learning in the ambulance service.

DESIGN

The study had an inductive and data-driven approach, guided by phenomenological epistemology.

METHODS

Twenty-seven Swedish nurse preceptors were interviewed in three focus groups and four dyadic interviews between October 2019 and April 2020. The data were analysed with reflexive thematic analysis.

FINDINGS

The nurse preceptors use several learning strategies, focusing on a socialization process and a clinical competence process, intertwined during clinical practice to support the development of a situated professional identity and a clinical decision-making competence. Supportive structures facilitate a progressive learning strategy when addressing desired skills and cognitive abilities in teamwork processes and clinical judgement.

CONCLUSION

Supporting novice clinicians, prior to and during clinical practice in the ambulance service, should include medical assessment skills, situation awareness and processes for effective teamwork. Further, novice clinicians need to develop complex cognitive abilities to deal with the dynamic nature of decision-making in ambulance care.

IMPACT

The study findings show contextual strategies, previously not described and desired competencies when supporting learning for registered nurses in the ambulance service. A theoretical grounding in episteme, techne, phronesis and situation awareness may guide educators at universities, managers in the ambulance service, preceptors and novice clinicians worldwide in the planning and performance of teaching and learning in the ambulance service.

Reliability and validity evaluation of the chinese version of the ethical sensitivity questionnaire for nursing students

BACKGROUND

Advances in technology and the expansion of nursing roles have led to complex ethical issues in nursing. Nursing students are the future clinical nursing workers and practitioners. The ethical sensitivity of nursing students is very important to the professional development of nursing students, which can strengthen the ethical cognition of nursing students, improve the ethical decision-making ability of nursing students, and is beneficial to the development of nursing students in the process of clinical practice and nursing education. However, there are no instruments to evaluate the ethical sensitivity of nursing students in China. Therefore, the purpose of this study is to evaluate the validity and reliability of the Chinese version of the Ethical Sensitivity Questionnaire for Nursing Students (ESQ-NS).

METHODS

After obtaining the authorization of the author of the original scale, the study used the Brislin back-translation method for translation. An exploratory factor analysis (EFA) and a confirmatory factor analysis (CFA) were performed to examine the underlying factor structure of the translated questionnaire. The Cronbach alpha coefficient, the test-retest reliability, and the corrected item-total correlation were calculated to verify the internal consistency of the scale.

RESULTS

The Chinese version of ESQ-NS retained 13 items. Exploratory factor analysis (EFA) extracts four common factors, and the cumulative variance contribution rate is 62.479%. The CFA reached the adaptive standard, and the discriminant validity of the scale was good. The Cronbach alpha coefficient of this scale was 0.821, and 4 dimensions were between 0.708 and 0.738. The results of the test-retest showed that Pearson's correlation coefficient of the overall ESQ-NS was 0.814. Corrected item-total correlation ranged from 0.337 to 0.542.

CONCLUSIONS

The Chinese version of the ESQ-NS has good reliability and validity, which can be used to evaluate the level of ethical sensitivity of nursing students in China.

Ambulance clinicians' attitudes to older patients' self-determination when the patient has impaired decision-making ability: A Delphi study

OBJECTIVE

The proportion of older people is increasing and reflects in the demand on ambulance services (AS). Patients can be more vulnerable and increasingly dependent, especially when their decision-making ability is impaired. Self-determination in older people has a positive relation to quality of life and can raise ethical conflicts in AS. Hence, the aim of this study was to empirically explore attitudes among Swedish ambulance clinicians (ACs) regarding older patients' self-determination in cases where patients have impaired decision-making ability, and who are in urgent need of care.

MATERIALS AND METHODS

An explorative design was adopted. A Delphi technique was used, comprising four rounds, involving a group (N = 31) of prehospital emergency nurses (n = 14), registered nurses (n = 10) and emergency medical technicians (n = 7). Focus group conversations (Round 1) and questionnaires (Rounds 2-4) generated data. Round 1 was analysed using manifest content analysis, which ultimately resulted in the creation of discrete items. Each item was rated with a five-point Likert scale together with free-text answers. Consensus (≥70%) was calculated by trichotomising the Likert scale.

RESULTS

Round 1 identified 108 items which were divided into four categories: (1) attitudes regarding the patient (n = 35), (2) attitudes regarding the patient relationship (n = 8), (3) attitudes regarding oneself and one's colleagues (n = 45), and (4) attitudes regarding other involved factors (n = 20). In Rounds 2-4, one item was identified in the free text from Round 2, generating a total of 109 items. After four rounds, 72 items (62%) reached consensus.

CONCLUSIONS

The findings highlight the complexity of ACs' attitudes towards older patients' self-determination. The respect of older patients' self-determination is challenged by the patient, other healthcare personnel, significant others and/or colleagues. The study provided a unique opportunity to explore self-determination and shared decision-making. AS have to provide continued ethical training, for example to increase the use of simulation-based training or moral case deliberations in order to strengthen the ACs' moral abilities within their professional practice.

IMPLICATIONS FOR PRACTICE

Ambulance services must develop opportunities to provide continued training within this topic. One option would be to increase the use of simulation-based training, focusing on ethical aspects of the care. Another option might be to facilitate moral case deliberations to strengthen the ACs' abilities to manage these issues while being able to share experiences with peers. These types of interventions should illuminate the importance of the topic for the individual AC, which, in turn, may strengthen and develop the caring abilities within an integrated care team.