Caring Work, Personal Obligation and Collective Responsibility

Development and Initial Validation of the Stress of Conscience Questionnaire

Stress in health care is affected by moral factors. When people are prevented from doing ‘good’ they may feel that they have not done what they ought to or that they have erred, thus giving rise to a troubled conscience. Empirical studies show that health care personnel sometimes refer to conscience when talking about being in ethically difficult everyday care situations. This study aimed to construct and validate the Stress of Conscience Questionnaire (SCQ), a nine-item instrument for assessing stressful situations and the degree to which they trouble the conscience. The items were based on situations previously documented as causing negative stress for health care workers. Content and face validity were established by expert panels and pilot studies that selected relevant items and modified or excluded ambiguous ones. A convenience sample of 444 health care personnel indicated that the SCQ had acceptable validity and internal consistency (Cronbach’s alpha exceeded 0.83 for the overall scale). Explorative factor analysis identified and labelled two factors: ‘internal demands’ and ‘external demands and restrictions’. The findings suggest that the SCQ is a concise and practical instrument for use in various health care contexts.

The Effect of the Use of Discretion on Occupational Therapists' Professional Identity

Introduction:

In the United Kingdom, one strand of New Labour's welfare reform agenda was the introduction of the Condition Management Programme. In many areas of the United Kingdom, occupational therapists took a leading role in service delivery. This research article examines occupational therapists' use of discretion within the programme and its effect on their professional identity.

Method:

In-depth face-to-face interviews were undertaken with 13 staff members employed by the Condition Management Programme, including six occupational therapists. Interview transcripts were analysed thematically using ATLAS.ti 6 software as a data management tool.

Findings:

Within Condition Management Programmes, managers had a large amount of freedom in service design and created a service staffed in the majority by occupational therapists. While some decisions were made as part of a multidisciplinary team, occupational therapists were allowed considerable clinical autonomy in delivering the service. The impact of this autonomy on their professional identity is discussed.

Conclusion:

As a central part of the Condition Management Programme service, occupational therapists and other allied health professionals were allowed considerable autonomy. Concurrently, occupational therapists reported a strong professional identity. There is a need for further research within mainstream National Health Service departments to examine how discretion affects professional identity.

'Working behind the scenes'. An ethical view of mental health nursing and first-episode psychosis

The aim of this study was to explore and reflect upon mental health nursing and first-episode psychosis. Seven multidisciplinary focus group interviews were conducted, and data analysis was influenced by a grounded theory approach. The core category was found to be a process named 'working behind the scenes'. It is presented along with three subcategories: 'keeping the patient in mind', 'invisible care' and 'invisible network contact'. Findings are illuminated with the ethical principles of respect for autonomy and paternalism. Nursing care is dynamic, and clinical work moves along continuums between autonomy and paternalism and between ethical reflective and non-reflective practice. 'Working behind the scenes' is considered to be in a paternalistic area, containing an ethical reflection. Treating and caring for individuals experiencing first-episode psychosis demands an ethical awareness and great vigilance by nurses. The study is a contribution to reflection upon everyday nursing practice, and the conclusion concerns the importance of making invisible work visible.

Understanding feticide: an analytic review

The medical procedure of 'feticide' has been used in clinical practice since the early 1990s in the UK. The procedure constitutes a sensitive aspect of late termination of pregnancy (TOP), an issue that is in itself contentious. The procedure has attracted attention from academic and policy commentators, but recently the medical profession has expressed some uncertainty with respect to the legal position of live birth following TOP, and professional discretion in providing feticide. To understand the meaning of these comments better, we argue that it is helpful to acknowledge the rhetoric that shapes the academic discourse on feticide. In this paper, we review how feticide has been conceptualised within academic discourse, demonstrating that the concept has multiple meanings, some of which could be considered politically charged. We then consider some examples of the comments made about the legal uncertainties of feticide, highlighting assumptions made about the problematic nature of professional discretion. Ultimately, we suggest that a better understanding of the context of feticide is needed to ensure that future research in this area of health care engages adequately with issues of professional discretion.

Relational practice and nursing obligations

Nursing relationships and the enactment of nursing values and goals in contemporary healthcare contexts are becoming increasingly challenging. Using a relational inquiry lens, the authors examine the interface of relationships, ethics, and effective nursing practice and the way in which personal and contextual elements continuously influence and shape nursing relationships in many ways. The nursing obligations underpinning relational practice are examined, and the way in which relational inquiry can enhance nurses' ability to navigate through the highly complex, multifaceted, and contextually dependent moments of contemporary nursing practice is illustrated.

The ethics of everyday practice: healthcare environments as moral communities

Traditional approaches to bioethics, that privilege impartiality and objectivity and that focus primarily on moral reasoning, are relatively silent on the moral habitability of healthcare environments. Nurses and others in "the trenches" of healthcare are increasingly voicing the need to address everyday ethical issues, interdisciplinary tensions, and systemic concerns, in addition to the ethics of high-profile medical cases. Attention to the institutional processes that shape and constrain ethical dialogue and practice is required. In this article, the call is made for a shift in thinking about ethics in healthcare.

Anaesthesia care of older patients as experienced by nurse anaesthetists

This article analyses problem situations in the context of anaesthesia care. It considers what it means for nurse anaesthetists to be in problematic situations in the anaesthesia care of older patients. Benner's interpretive phenomenological approach proved useful for this purpose. Paradigm cases are used to aid the analysis of individual nurses' experiences. Thirty narrated problematic anaesthesia care situations derived from seven interviews were studied. These show that experienced nurse anaesthetists perceive anaesthesia care as problematic and highly demanding when involving older patients. To be in problematic anaesthesia care situations means becoming morally distressed, which arises from the experience or from being prevented from acting according to one's legal and moral duty of care. An important issue that emerged from this study was the need for an ethical forum to discuss and articulate moral issues, so that moral stress of the kind experienced by these nurse anaesthetists can be dealt with and hopefully reduced.