"Never again" stories of nurses: dilemmas in nursing practice

Shifting Professional Identity Among Indonesian Medical Practitioners During the COVID-19 Pandemic

The COVID-19 pandemic has had a significant impact on medical practitioners' professional identities due to its novelty and intensity. Using constructivist grounded theory, we investigated how the COVID-19 pandemic shifted individuals' identities as medical practitioners in Indonesia, where the pandemic caused high death rates among healthcare workers, particularly medical practitioners. By interviewing 24 medical practitioners and analyzing relevant documents and reports, we developed a grounded theory of professional identity shifts. We found two patterns: (1) identity growth, in which the medical practitioners thrive and claimed stronger professional identities, and (2) psychological and moral distress leading to attrition, facilitated adaptation, or professional identity collapse. We also found several primary protective factors including religious beliefs, good leadership, team cohesion, healthy work boundaries, connection to significant others, and public acknowledgment. Without adequate protective factors, medical practitioners experienced difficulties redefining their professional identities. To cope with the situation, they focused on different identities, took some time off, or sought mental health support, resulting in facilitated adaptation. Others resorted to attrition or experienced professional identity collapse. Our findings suggest that medical practitioners' experience of professional identity shifts can be improved by providing medical practitioners with opportunities for knowledge updates, better organizational leadership and work boundaries, strategies to enhance team cohesion, and other improvements to medical systems.

Refinement of the Intensive Care Unit Complexity Assessment and Monitoring to Ensure Optimal Outcomes III Acuity Tool

BACKGROUND

The Intensive Care Unit (ICU) Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO) acuity tool quantifies patient acuity in terms of nursing cognitive workload complexity.

OBJECTIVES

The aim of this study was to refine the ICU CAMEO II acuity tool. An expert panel of nursing staff from 4 pediatric ICUs convened to refine the CAMEO II across a large, freestanding children's hospital in the United States.

METHOD

This study used a modified Delphi technique.

RESULTS

Through a series of 4 Delphi rounds, the expert panel identified Domains of Care and nursing care items that were suitable to be collapsed or bundled. The number of Domains of Care decreased from 18 to 10. Each of the expert panel members then completed the ICU CAMEO II tool and the newly revised tool, ICU CAMEO III, on 5 to 10 patients. Sixty completed ICU CAMEO II tools, and ICU CAMEO III tools were available for comparison. The average difference of the 2 tools' total scores was 5 points (minimum, 4; maximum, 7). The level of agreement between the 2 tools by CAMEO Complexity Classification level (I-V) was 90%.

DISCUSSION

The ICU CAMEO III acuity tool is a streamlined measure to describe and quantify the acuity of pediatric critical care nursing. Use of this acuity measure will support projection of staffing models, staffing assignments, and benchmarking across pediatric ICUs. Further research is underway to validate the CAMEO III for multisite use.

Supporting nurses' recovery during and following the COVID-19 pandemic

Research suggests that working during traumatic events can lead to deteriorating physical and mental health for nurses, a phenomenon that has been demonstrated during the coronavirus 2019 (COVID-19) pandemic. However, research has also shown that there are evidence-based strategies that can be used to assist nurses in their recovery from such events. Promoting awareness among individual nurses about the effects of COVID-19 enables them to adopt positive coping strategies, both on an individual and organisational level. This article details strategies including formal and informal debriefing, taking regular breaks, and using stress mitigation strategies during shifts. The article also discusses the potential for post-traumatic psychological growth. This acknowledges that while working in a healthcare environment during COVID-19 can be extremely challenging, it also enables nurses to experience personal growth such as the development of emotional intelligence. As nurses adapt to the 'new normal' of working during COVID-19, healthcare organisations should ensure that they provide nurses with the support that enables them to recover effectively.

The Measurement of Pediatric Inpatient Nursing Using the Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) Tool

PURPOSE

Physiologic measurement of patient acuity has been used to predict patient outcomes, length of stay, and resource utilization. To date, these tools are not sufficiently comprehensive to inform nurse staffing assignments and have limited practical application. The Complexity Assessment and Monitoring to Ensure Optimal Outcomes (CAMEO©) acuity tool was initially developed and validated to quantify patient acuity in terms of complexity of nursing cognitive workload in pediatric intensive care units (ICU). This article describes development and implementation of the Inpatient CAMEO© in the pediatric inpatient setting.

DESIGN AND METHODS

Utilizing a modified Delphi technique, an expert panel convened to scale and implement the Inpatient CAMEO© in the pediatric inpatient units through four Delphi rounds.

RESULTS

The expert panel identified care items unique to the pediatric inpatient setting and assigned a cognitive workload scale of 1-5. To consolidate the tool, the panel identified items to be classified as "Standard of Care" and developed a new baseline score for the Inpatient CAMEO©. Expert panel members served as unit-based ambassadors to foster the expansion and implementation of the new Inpatient CAMEO©.

CONCLUSIONS

The Inpatient CAMEO© describes and quantifies acuity beyond the intensive care setting. The implementation and use of the Inpatient CAMEO© was accomplished through unit-based ambassadors and the support of leadership.

PRACTICE IMPLICATIONS

Quantifying nursing cognitive workload in both direct and indirect care is important to determining nursing assignments and comprehensive staffing models in the pediatric inpatient setting.

The Critical Incident Technique: Method or Methodology?

The critical incident technique (CIT) is a qualitative research tool that is frequently used in health services research to explore what helps or hinders in providing good quality care or achieving satisfaction with care provision. However, confusion currently exists on the nature of the CIT: Is it a method for data collection and analysis or a methodology? In this article, I explain why this distinction is important and I argue that the CIT is a methodology (and not a method) for the following reasons: Key methodological dimensions are described for the CIT; it has a clear focus; studies that apply this technique make use of various methods for data collection and analysis; it describes, explains, evaluates, and justifies the use of a specific format for those methods; it implies philosophical and practical assumptions; and studies that use the CIT cannot easily make use of additional methodologies simultaneously.

"We Won't Retire Without Skeletons in the Closet": Healthcare-Related Regrets Among Physicians and Nurses in German-Speaking Swiss Hospitals

Physicians and nurses are expected to systematically provide high-quality healthcare in a context marked by complexity, time pressure, heavy workload, and the influence of nonclinical factors on clinical decisions. Therefore, healthcare professionals must eventually deal with unfortunate events to which regret is a typical emotional reaction. Using semistructured interviews, 11 physicians and 13 nurses working in two different hospitals in the German-speaking part of Switzerland reported a total of 48 healthcare-related regret experiences. Intense feelings of healthcare-related regrets had far-reaching repercussions on participants' health, work-life balance, and medical practice. Besides active compensation strategies, social capital was the most important coping resource. Receiving superiors' support was crucial for reaffirming professional identity and helped prevent healthcare professionals from quitting their job. Findings suggest that training targeting emotional coping could be beneficial for quality of life and may ultimately lead to lower job turnover among healthcare professionals.

Understanding how nurses ration care

Purpose

The purpose of this paper is to explore how nurses make decisions to ration care or leave it undone within a clinical environment that is controlled by systems level cost containment. The authors wanted to find out what professional, personal and organisational factors contribute to that decision-making process. This work follows previous international research that explored missed nursing care using Kalisch and Williams’ MISSCARE survey.

Design/methodology/approach

The authors drew on the care elements used by Kalisch and Williams, asking nurses to tell us how they decided what care to leave out, the conduits for which could include delaying care during a shift, delegating care to another health professional on the same shift, handing care over to staff on the next shift or leaving care undone.

Findings

The findings suggest that nurses do not readily consider their accountability when deciding what care to leave or delay, instead their priorities focus on the patient and the organisation, the outcomes for which are frequently achieved by completing work after a shift.

Originality/value

The actions of nurses implicitly rationing care is largely hidden from view, the consequences for which potentially have far reaching effects to the nurses and the patients. This paper raised awareness to hidden issues facing nurses within a cycle of implicitly rationing care, caught between wanting to provide care to their patients, meeting the organisation’s directives and ensuring professional safety. Rethinking how care is measured to reflect its unpredictable nature is essential.

Relationship of adverse events and support to RN burnout

Registered nurse (RN) "second victims" are RNs who are harmed from their involvement in medical errors. This study used the conceptual model nurse experience of medical errors and found a relationship between RN involvement in preventable adverse events and 2 domains of burnout: emotional exhaustion (P = .009) and depersonalization (P = .030). Support to RNs involved in preventable adverse events was inversely related to RN emotional exhaustion (P < .001) and depersonalization (P = .003) and positively related to personal accomplishment (P = .002).

'Practice what you preach': Nurses' perspectives on the Code of Ethics and Service Pledge in five South African hospitals

BACKGROUND

A recent focus of the global discourse on the health workforce has been on its quality, including the existence of codes of ethics. In South Africa, the importance of ethics and value systems in nursing was emphasised in the 2011 National Nursing Summit.

OBJECTIVE

The study explored hospital nurses' perceptions of the International Code of Ethics for Nurses; their perceptions of the South African Nurses' Pledge of Service; and their views on contemporary ethical practice.

METHODS

Following university ethics approval, the study was done at a convenience sample of five hospitals in two South African provinces. In each hospital, all day duty nurses in paediatric, maternity, adult medical, and adult surgical units were requested to complete a self-administered questionnaire. The questionnaire focused on their perceptions of the Code of Ethics and the Pledge, using a seven-point Likert scale. STATA(®) 13 and NVIVO 10 were used to analyse survey data and open-ended responses, respectively.

RESULTS

The mean age of survey participants (n=69) was 39 years (SD=9.2), and the majority were female (96%). The majority agreed with a statement that they will promote the human rights of individuals (98%) and that they have a duty to meet the health and social needs of the public (96%). More nuanced responses were obtained for some questions, with 60% agreeing with a statement that too much emphasis is placed on patients' rights as opposed to nurses' rights and 32% agreeing with a statement that they would take part in strike action to improve nurses' salaries and working conditions. The dilemmas of nurses to uphold the Code of Ethics and the Pledge in face of workplace constraints or poor working conditions were revealed in nurses' responses to open-ended questions.

CONCLUSION

Continuing education in ethics and addressing health system deficiencies will enhance nurses' professional development and their ethical decision-making and practice.

Locating nursing students' chronicles

Analysis of students' stories and reflections has contributed to faculty members' knowledge of the student experience. Examining different sources of nursing students' narratives might lead to further understanding of what they think, feel, and perceive during their educational pursuits. Whereas some texts provide ample insights into student life, others are fragmentary or not recorded, evaluated, or systematically investigated. To achieve a different appreciation of stories and other texts calls for faculty research. What is discovered might change teaching approaches.

Using Storytelling to Elicit Design Guidance for Medical Devices

Medical device designers must understand the complex context of use within a health care environment to ensure product usability. Designers must overcome domain-specific obstacles during usability research, such as patient privacy standards, which prevent designers from observing practitioners in context. In this project, we investigated storytelling as an alternative elicitation method for medical device requirements when direct observations are limited or not possible. While gathering requirements for an infusion pump, we compared the types of information elicited by focus groups, interviews, and storytelling sessions. Several advantages and implications for the use of storytelling in usability research are discussed.

Early indicators and risk factors for ethical issues in clinical practice

PURPOSE

Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify risk factors and early indicators of ethical conflicts.

METHODS

Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, their risk factors and early indicators, nurse actions, and situational outcomes. Two nurse researchers independently analyzed and categorized data using a constant comparison technique.

FINDINGS

Most of the ethically difficult situations pertained to end-of-life care for children and adults. Conflicts in interpersonal relationships were prevalent. Nurses were especially moved by patient and family suffering and concerned about patient vulnerability, harm-benefit ratio, and patient autonomy. Researchers discovered risk factor categories for patients, families, healthcare providers, and health systems. Additionally, researchers found subcategories in six major categories of early indicators: signs of conflict, patient suffering, nurse distress, ethics violation, unrealistic expectations, and poor communication.

CONCLUSIONS

Nurses are keenly aware of pertinent risk factors and early indicators of unfolding ethical conflicts. Many nurses reported feeling powerless in the face of ethical conflict. Research that develops interventions to strengthen nurses' voices in ethically difficult situation is warranted.

CLINICAL RELEVANCE

Nurses are in a key position to identify patient situations with a high risk for ethical conflict. Initiating early ethics consultation and interventions can alter the course of pending conflicts and diminish the potential for patient and family suffering and nurses' moral distress.

Nurses’ ethical reflections on caring for people with malodorous exuding ulcers

The aim of this study was to illuminate nurses’ reflections on obstacles to and possibilities for providing care as desired by people with malodorous exuding ulcers. Six nurses who took part in a previous study were interviewed. The participants were shown an illustration with findings from a study that elucidated the meaning of living with malodorous exuding ulcers. They were asked to reflect on the obstacles to and possibilities of providing the care desired by the patients. Twelve audio-recorded transcribed interviews were analysed using qualitative content analysis. Our interpretations of participants’ reflections on the obstacles and possibilities while caring for such patients revealed one theme: striving to ‘do good’ and ‘be good’. The obstacles were formulated as subthemes: experiencing clinical competence constraints, experiencing organizational constraints, experiencing ineffective communication, fearing failure, and experiencing powerlessness. The possibilities were formulated by the subthemes: spreading knowledge about ulcer treatments, considering wholeness, and creating clear channels of communication. A multiprofessional team could overcome the identified obstacles and provide structure, competencies, commitment and support to ‘do good’ for patients and ‘be good’ nurses.

The role of guidelines in ethical competence-building: perceptions among research nurses and physicians

The aim of the present study was to describe and explore the perception of ethical guidelines and their role in ethical competence-building among Swedish physicians and research nurses. Twelve informants were interviewed in depth. The results demonstrated that the informants had a critical attitude towards ethical guidelines and claimed to make little use of them in practical moral judgements. Ethical competence was seen primarily as character-building, related to virtues such as being empathic, honest and loyal to patients. Ethical competence was assumed to be learned through good examples, role models and practical experience, while ethical guidelines were not perceived as valuable in this process. In order to improve the staff's familiarity with and the usability of ethical guidelines, the workplace needs to provide opportunities for ethical dialogues. In such discussions, argumentation can improve, virtues can be developed and guidelines can be usefully invoked.

Ethical dilemmas: the experiences of israeli nurses

In this study I explored ethical dilemmas in nursing to gain a better understanding of nurses' work and their professional status. Qualitative data on ethical dilemmas were collected by interviewing 52 nurses in 18 hospitals and health maintenance organizations. The transcribed interviews were analyzed using a stepwise method. Results indicate a large number of dilemmas that can be divided into five main categories: caring vs. following formal codes; fair process vs. fair outcome; organizational standards vs. family agenda; autonomy vs. deference to higher authority, and guarding secrecy vs. duty to report. The study findings might enhance nurses' ability to cope with ethical dilemmas and bring about change in their professional status. In addition, the results might guide nurses and their supervisors toward developing practitioner programs for nurses that deal with ethical aspects. All these might reduce the expected shortage of nurses and improve the ability of the system to provide quality health care.

The importance of time in ethical decision making

Departing from a contemporary novel about a boy who is going to die from leukaemia, this article shows how the dimension of time can be seen as a morally relevant category that bridges both 'dramatic' issues, which constitute the dominant focus of bioethical decision making, and 'undramatic' issues, which characterize the lived experience of patients, relatives and health care workers. The moral task of comparing the various time dimensions of a given situation is explained as an act of 'synchronizing' the clocks. Ethical sensitivity and competence are presented as core skills that allow a continuity of care in situations where dramatic issues seem to be resolved, but undramatic ones are still not addressed. A nine-step model of shared decision making is proposed as an approach to identifying critical junctures within an illness trajectory and synchronizing the clocks of the involved actors.

Ethical problems observed by student nurses

This descriptive study was conducted to determine nursing students' observation of ethical problems encountered in their clinical practice. Data were collected through a questionnaire from 153 volunteer nursing students at a university-based nursing school in Ankara, Turkey. The students reported that some patients are either physically or psychologically mistreated by doctors and nurses; they were not given appropriate information; they were subjected to discrimination according to their socio-economic situation; and their privacy was ignored. The findings reveal that nurses' own unethical behaviors contribute to a rise in ethical problems. It is argued that nurses should internalize their professional and ethical roles in order to provide safe and ethical care and be good role models for students.

"Talk to me--I'm human": the story of a girl, her personhood, and the failures of health care

Perspectives on the concept of personhood and its relationship to health care delivery are considered in the context of the life of an adolescent with multiple disabilities. One phenomenological interview lasting 3 hours illuminated life-long experiences of suffering, healing, and the quest to be treated as human, as perceived by a 16-year-old girl disfigured by multiple cancer treatments. Age-appropriate development is the ground of her existence, whereas the quality of relationships with care providers and the extent to which they demonstrate regard for her value as a person are figural. Health care providers have often failed to interact with her in ways supporting dignity and growth, treating her with "care" that is antithetical to the aims of their professions. The case has relevance for health care education and practice, challenging professionals to examine their views on personhood and self-care agency, and the ways in which those views impact the care they provide.

Analysis of accident and emergency doctors' responses to treating people who self-harm

Self-harm is a prevalent phenomenon regularly faced by doctors and nurses working in accident and emergency (A&E) departments. We argue that the treatment decisions A&E doctors make are fundamental to decreasing the high risk of suicide among this group. In this article we present a qualitative study exploring how doctors working in A&E respond to treating people who self-harm. In total, five A&E doctors were interviewed and the data were analyzed using interpretative phenomenological analysis. Three main themes were extracted: treating the body, silencing the self, and mirroring cultural and societal responses to self-harm. Within these themes, we identified both facilitative and unhelpful aspects of the relationships between people who self-harm and A&E doctors. We consider the clinical implications of these findings within the context of A&E doctors having limited opportunities to address the relational nature of the care they offer to this group.

Ladies without lamps: nurses in Bangladesh

In this article, I explore the experiences and concerns of Bangladeshi nurses. I have based this on a larger ethnographic study that was conducted in a ward of a government teaching hospital in Bangladesh. The study shows how the values and norms of Bangladeshi society have shaped the life of Bangladeshi nurses, that they do scarcely any nursing work, and that they suffer from various negative social images. I argue, through this article, that the role, image, and concerns of Bangladeshi nurses have changed dramatically from the ideal image of nursing, and are dissimilar from the ways nursing is practiced in many other parts of the world.

The (dis)appearance of the dying patient in generalist hospital and care home nurses' talk about the patient

This article explores interview data from a study of 50 Norwegian generalist nurses' focus group accounts of caring for dying patients in the hospital and care home. An eclectic discourse analytic approach was applied to nurses' accounts of the patient and three discursive contexts of reference to the patient were identified: the 'taken as read' patient, the patient paired with particular characteristics and the patient as psychologically present. Talk about the patient falls mainly into the first two contexts, which position the patient in relation to three closely related discursive processes: individualization, anonymization and objectification. The third context presents the patient as a person with a particular identity. The analysis is discussed in a broader philosophical and sociological context in which we return to some of the theoretical work on death and dying of the 1990s and the topic of sequestration. We suggest that nurses' talk about the patient can be heard to participate in a continuing sequestration of the dying patient in healthcare institutions focused on 'result-oriented' care.

Inconsistent use of the critical incident technique in nursing research

AIM

This paper is a critique of the use of critical incident technique in nursing and a demonstration of how its development has resulted in inconsistency and confusion.

BACKGROUND

Critical incident technique is used globally by nurse researchers to explore a plethora of nursing issues. Its main strengths are flexibility and adaptability, but its popularity has resulted in ambiguity and confusion.

DATA SOURCES

A search of the CINAHL database for the period 1956-2007 was performed using the search terms critical incident technique and nursing. Together with hand searching, this produced a total of 59 papers. The papers were analysed according to country of origin, research topic, sample size, data collection method, inclusion/exclusion criteria, data analysis and terminology. We then categorized the results of this analysis depending on similarities and differences in the papers.

DISCUSSION

We focus on two areas: methodology and terminology. From a methodological perspective critical incident technique has become inconsistent and in relation to terminology, the diverse language associated with the technique has created confusion. Moreover, issues of rigour may be compromised as a result of this inconsistency. A great deal of inconsistency has been created by nurse researchers' attempts to advance critical incident technique. This has led to confusion, which is not helpful for advancing nursing knowledge.

CONCLUSION

While embracing the continued development of critical incident technique, we advocate a standardized approach to its use. Unless nurse researchers are alert to the methodological and terminological inconsistencies in use of the critical incident technique, it risks becoming an interminable quagmire through which navigation will be impossible.

Willingness and its relevance to nursing

Nursing practice is embedded in contexts that inhibit or constrain emancipatory relationships. This article explores willingness in relation to agency and actualization fostered by emancipative relationships in nursing practice. Opportunities for emancipative choice are possible only when nurses are willing to engage in critical reflection, authentic discourses, and risk congruent action within the constraints of dominant paradigms.