Investigating the relationship between nurses' workplace behaviour and perceived levels of ethical leadership in managers

BACKGROUND

There is increasing research interest in the relationship between ethical leadership and deviant workplace behaviour. Ethical leadership encompasses altruism, courage, ethical orientation, integrity and fairness. Examples of deviant workplace behaviours include theft, fraud, sabotage, assault, abuse, manipulation and bullying. It appears that when leaders are fair and emphasise ethical conduct, followers are less inclined to engage in deviant workplace behaviour.

AIM

To investigate the relationship between nurses' self-rated levels of deviant workplace behaviour and perceived levels of ethical leadership in managers.

METHOD

For this descriptive correlational study, 355 nurses from one university hospital in Egypt responded to an online questionnaire comprising the Ethical Leadership Scale and the Workplace Deviance Behavior Scale. Descriptive and inferential statistics were used to explore results and examine the relationships between study variables.

RESULTS

There was a statistically significant negative relationship between respondents' self-rated levels of deviant workplace behaviour and their perceptions of levels of ethical leadership in managers. The results appeared to confirm previous research. Nurses who feel that they are treated fairly by their managers tend to have positive attitudes towards work, colleagues and management.

CONCLUSION

Ethical leadership on the part of managers is a significant determinant of nurses' behaviour in the workplace and should therefore be fostered by healthcare organisations.

Using therapeutic lies - an ethical challenge for nurses when caring for people with dementia

People living with dementia can become vulnerable when experiencing symptoms such as memory loss and disorientation, as well as stigma attached to the condition. The care of people with dementia is fraught with ethical dilemmas and challenges regarding how nurses should respond to situations that put patients at risk of distress. For example, if a person with dementia asks to see a deceased relative, a nurse may have to decide whether to tell the truth, or a 'white lie' to avoid distress. This article examines the debates around the use of such 'therapeutic lying' when caring for people with dementia and provides guidance on how nurses could use this technique while protecting the individual's best interests.

Is therapeutic lying contradictory to person-centred care? Toward understanding the connection

AIM

There is a lack of clarity about therapeutic lying in the context of everyday dementia care. This study provides conceptual clarity on how the term is used and considers the concept in relation to person-centred care.

METHODS

Rodgers' (1989) evolutionary framework of concept analysis was employed. A systematic multiple database search was conducted and supplemented with snowballing techniques. Data were analysed thematically through an iterative process of constant comparison.

RESULTS

This study highlighted that therapeutic lying is intended to be used in the person's best interests for the purpose of doing good. However, its potential for doing harm is also evident. Its use in the literature has increased with the general trend towards becoming more accepted in the discourse. A continuum emerged depending on the degree to which a lie departs from the truth. Emerging guidelines were also evident as to when a lie could or could not be justified.

CONCLUSION

The term therapeutic lying, was contrasted with aspects of person-centred care and was found to be problematic. We conclude that there may be more pragmatic ways of constructing language around the care of people with dementia which could be less stigmatising.

A pilot study on the global practice of informed consent in paediatric dentistry

Background

Conducting oral treatment early in the disease course, is encouraged for better health outcomes. Obtaining informed consent is an essential part of medical practice, protecting the legal rights of patients and guiding the ethical practice of medicine. In practice, consent means different things in different contexts. Silver Diamine Fluoride (SDF) and Silver Fluoride (SF) is becoming popular and cost effective methods to manage carious lesions, however, cause black discolouration of lesions treated. Obtaining informed consent and assent is crucial for any dental treatment-and has specific relevance with SDF/ SF treatments.

Methods

The aim of this paper is to describe informed consent regulations for dental care in a selection of countries, focusing on children and patients with special health care needs. An online survey was shared with a convenience sample of dental professionals from 13 countries. The information was explored and the processes of consent were compared.

Results

Findings suggest that there are variations in terms of informed consent for medical practice. In Tanzania, South Africa, India, Kenya, Malaysia and Brazil age is the determining factor for competence and the ability to give self-consent. In other countries, other factors are considered alongside age. For example, in Singapore, the United Kingdom, and the United States the principle of Gillick Competence is applied. Many countries' laws and regulations do not specify when a dentist may overrule general consent to act in the "best interest" of the patient.

Conclusion

It is recommended that it is clarified globally when a dentist may act in the "best interest" of the patient, and that guidance is produced to indicate what constitutes a dental emergency. The insights gathered provide insights on international practice of obtaining informed consent and to identify areas for change, to more efficient and ethical treatment for children and patients with special needs. A larger follow up study is recommended to include more or all countries.

Health, mental health, and hearing indigenous voices

OBJECTIVE

To identify the issues raised by the unsuccessful Voice referendum and propose removal of barriers to reporting and prevention of family violence in remote communities as the most ambitious measure of success in hearing First Nations voices.

CONCLUSIONS

The Voice referendum was partly justified to improve the mental health of First Nations Australians, despite concern the process and its outcome might worsen both. Aboriginal and Torres Strait Islander leaders revealed the tensions that arise between individual and communal interests when marginalised groups fight for self-determination. While a unified First Nation Voice is likely to amplify prominent messengers, we should also be interested in hearing diverse, dissenting voices. As the most marginalised group within a marginalised community, the ability to hear the voices of women and children subject to family violence in rural/remote Australian communities may be the best measure of success in overcoming the barriers that was the motivation for the referendum.

Trends and ethical issues in nursing during disasters: A systematic review

BACKGROUND

During a disaster, nurses face complex ethical challenges because of risky situations. It is necessary to identify trends and ethical issues of nurses in disasters to improve the quality of care and impact for nurses.

METHOD

This systematic review enrolled in the international registration with PROSPERO: CRD42022350765. We searched the following databases: PubMed, EBSCO MEDLINE, SCOPUS, ProQuest, ScienceDirect, and Sage Pub. The inclusion criteria were developed according to PICO and D; are Population (F): involving nurses; intervention/Exposure (I): disaster, Comparison (C): none; outcome (O): ethical practice. And Design (D): qualitative, quantitative, and mixed methods. Years of publication were 2012-2022, with full text in English. The quality of study assessment used was The Joanna Briggs Institute (JBI) Critical Appraisal tool and Mixed Methods Appraisal Tool (MMAT) version 2018. Analysis used PICO synthesis.

RESULTS

There were 15 studies reviewed from 2093 results, including cross-sectional (4/15, 26.6%), qualitative (9/15, 60%), and mixed methods (2/15, 13.3%) studies. The types of disasters were: COVID-19 (7/15, 46.6%), infectious (4/15, 26.6%), and all disaster events (4/15, 26.6%). The main themes were: (1) ethical issues in disasters have the potential to address ethical dilemmas, (2) factors applying nursing ethics to support ethical decision-making in disasters, (3) strategies for applying ethics and dealing with ethical issues in disasters, and (4) the impact of applying ethics in disasters.

CONCLUSION

Applying ethics nursing in a disaster is influenced by various factors. This framework for ethical nursing in disasters aims to help nurses, educational institutions, and policymakers develop schemes or scenarios to enhance responsible ethical decisions in disasters.

Ethical decision-making in the administration of 'as required' antipsychotics to people with dementia in care homes

Antipsychotic medicines are often prescribed 'as required' to manage behavioural and psychological symptoms of dementia, despite evidence that these medicines have little benefit for people with dementia and have numerous adverse side effects, including sedation. It is the nurse's role to decide if and when to administer antipsychotic medicines that have been prescribed on an as required basis. This decision-making is underpinned by complex ethical considerations such as mental capacity, chemical restraint, quality of life and autonomy. Adopting a person-centred approach and considering the ethics, guidelines and legislation related to such decisions can support nurses to act in patients' best interests. This article uses two ethical frameworks - the four principles of biomedical ethics and the 'four quadrants' approach - to examine this complex issue and to demonstrate their use in the context of ethical decision-making in nursing practice.

Archaeology and social justice in island worlds

Ongoing discussions about the problems of white supremacy and colonialism in archaeology are useful but have not, thus far, fully considered the exacerbated effects of these issues on small islands. In this opinion piece, we, two white women academics from the Global North with extensive experience working in the Dutch Caribbean and the Hawaiian Islands, observe these exacerbated effects in governance, academic hegemony, and community relations, and call for more consideration of the effects of our discipline in small island contexts. Ultimately, in line with the observations of local, descendant, and Indigenous scholars, we argue that archaeologists must invest in de-colonial, antiracist, and social justice efforts in heritage fields and industries by foregrounding the wishes and needs of island communities. This may involve modifying or altogether abandoning current motivations and practices to build a discipline that can be a positive rather than a negative in island worlds.

Misinformation and Disinformation in Food Science and Nutrition: Impact on Practice

Food and nutrition are popular topics in the media and on social media. The ubiquity of social media has created new opportunities for qualified or credentialed experts in the scientific community to connect with clients and the public. It has also created challenges. Health and wellness gurus, or self-proclaimed experts, utilize social media platforms to garner attention through compelling narratives, build audience followings, and influence public opinion by sharing (often) misleading information about food and nutrition. The consequence of this can be the perpetuation of misinformation, which not only undermines a well-functioning democracy but also diminishes support for policies that are science or evidence based. Nutrition practitioners, clinician scientists, researchers, communicators, educators, and food experts need to encourage and model critical thinking (CT) to participate in our world of mass information and mitigate misinformation. These experts can play a vital role in the evaluation of information about food and nutrition against the body of evidence. This article explores the role of CT and ethics of practice in the context of misinformation and disinformation by providing a framework for engaging with clients and offering a checklist for ethical practice.

A Survey of Telemedicine Use by Doctors in District Hospitals in KwaZulu-Natal, South Africa

There is anecdotal evidence of informal telemedicine activity in KwaZulu-Natal (KZ-N), South Africa.

AIM

To determine the current extent of telemedicine in district hospitals in KZ-N; the range of clinical activities and technologies used; additional services needed; current knowledge and practice regarding legal, ethical, and regulatory issues; and the need to formalise telemedicine activities.

METHOD

A cross-sectional survey of telemedicine use by 143 doctors working at 22 District hospitals in KZ-N.

RESULTS

Most doctors (96%) participated in some form of telemedicine across a spectrum of disciplines, but more than half did not consider their activities to constitute telemedicine. To meet their needs, doctors have started their own informal services with colleagues, using mostly instant messaging and chat groups (WhatsApp). Some doctors indicated the need to formalise these services and establish additional services. Few doctors were aware of the national telemedicine guidelines and the required written informed consent for telemedicine was seldom obtained. This could have serious legal, regulatory, and ethical implications.

CONCLUSIONS

Practical clinical and technical guidelines and standard operating procedures need to be developed with the active participation of the clinical workforce. These should encourage innovation and greater use of telemedicine, including the use of instant messaging apps.

'No other alternative than to compromise': Experiences of midwives/nurses providing care in the context of scarce resources

Midwives and nurses play a critical role in safeguarding the lives of women in resource-constrained African countries. Working within the context of scarce resources may undermine their moral agency and hinder their ability to care. The purpose of this paper is to understand the influence of resource scarcity on midwifery and nursing care and practice. A critical ethnography was conducted in the obstetric department of three tertiary-level facilities in Ghana. Purposive sampling was used to recruit 30 midwives and nurses and semistructured interviews, field notes and documentary materials were used to generate in-depth understanding. Ethical approval was granted from Canada and Ghana and written, and ongoing informed consent was obtained from the participants. Five conceptual themes depicting the impact of scarce resources on midwifery and nursing care were discovered: compromised care, constrained care, dehumanized care, missed care and disengaged care. Improving the maternal health of women and averting avoidable maternal morbidity and mortality require governments and institutions to invest in health infrastructure that will support the delivery of ethical and safe midwifery care for women in their most vulnerable period.

Understanding the legal considerations of consent in nursing practice

Consent to treatment is a common, albeit complex, aspect of nursing practice. Over the past few years, laws have been strengthened to provide increased recognition of patient autonomy. This has meant that there is a greater onus placed on nurses to understand how consent is obtained from patients, the elements required to ensure any consent is valid, and how to proceed when it has been determined that a patient does not have the mental capacity to consent to treatment. This article explores some of the legal considerations that nurses should keep in mind when seeking consent from a patient.

Understanding and mitigating moral injury in nurses

Moral injury may be experienced when a person perpetrates, witnesses or fails to prevent an act that conflicts with their moral values and beliefs. The concept of moral injury has its origins in the context of military personnel encountering ethically challenging decisions during armed conflict. The term has been applied to healthcare and moral injury is increasingly acknowledged to be a challenge for healthcare professionals. Nurses across all specialties and settings are frequently required to make or witness ethically challenging decisions about patient care. The coronavirus disease 2019 (COVID-19) pandemic has increased nurses' risk of sustaining moral injury. This article discusses the manifestations of moral injury and its associated risk factors, including the effects of the COVID-19 pandemic. It also outlines various strategies that can be used to mitigate and/or prevent moral injury in nurses.

The evolution of epistemological methodologies in anatomy: From antiquity to modern times

Present day scenario regarding epistemological methods in anatomy is in sharp contrast to the situation during ancient period. This study aimed to explore the evolution of epistemological methodologies in anatomy across centuries. In ancient times Egyptian embalmers acquired anatomical knowledge from handling human bodies and likewise anatomical studies in India involved human dissection. Ancient Greeks used theological principles-based methods, animal dissection and human dissection in practice of anatomy. Human dissection was also practiced in ancient China for gaining anatomical knowledge. Prohibition of human dissection led to use of animal dissection in ancient Rome and the trend continued in Europe through Middle Ages. Epistemological methods used by Muslim scholars during Middle Ages are not clearly chronicled. Human dissection returned as primary epistemological method in Renaissance Europe and empirical methods were reinstated after ancient period in human dissection during 16th century. The situation further improved with introduction of pragmatic experiment based approach during 17th century and autopsy-based methods during 18th century. Advances in anatomical knowledge continued with advent of microscope-based methods and emergence of anatomical sections in practice of human dissection in 19th century. Introduction of human observational studies, medical imaging, and molecular methods presented more options in terms of epistemological methods for investigating the human body during 20th century. Onset of 21st century has witnessed dominance of technology-based methods in anatomy. Limited emphasis on ethics in epistemological methodologies since antiquity is a dark aspect of otherwise an eventful evolutionary journey but recent developments are in positive direction.

Understanding failings in patient safety: lessons from the case of surgeon Ian Paterson

While rare, incidents of inappropriate and/or unnecessary surgery do occur, so effective surveillance of surgical practice is required to ensure patient safety. This article explores the case of Ian Paterson, a consultant surgeon who was sentenced to 20 years in prison in 2017 for wounding with intent and unlawful wounding, primarily by undertaking inappropriate or unnecessary mastectomies. The article details the main points of the Paterson case, with reference to the subsequent government-commissioned inquiry and its recommendations. It also outlines various strategies for enhancing patient safety, including applying human factors theory, improving auditing, and rationalising NHS and private healthcare. The author concludes that nurses have a crucial role in the surveillance of surgical practice and that combined reporting of surgeons' practice across NHS and private healthcare organisations is required.

Risking vulnerability: Enacting moral agency in the is/ought gap in mental health care

AIM

To explore how healthcare providers in acute care mental health settings navigate ethically challenging situations, enact moral agency, practice in congruence with ethical standards and mitigate moral distress (MD).

DESIGN

Grounded theory, a qualitative methodology.

METHODS

Over 18 months between 2015 and 2017, we reviewed documents, conducted observations and interviewed multidisciplinary participants (N = 27) from inpatient and emergency departments. Participants either provided direct care (N = 14) or were in leadership positions (N = 13). Data were analysed iteratively using constant comparison, coding, memoing and theorizing, which continued until saturation was reached in July 2016.

FINDINGS

The basic social process of how healthcare professionals enacted moral agency, Risking Vulnerability, occurred in the context of Systemic Inhumanity, a constant source of MD. Participants Risked Vulnerability, balancing professional obligations, clinical expertise and organizational processes with their own vulnerability in the system as they strove to practice ethically. Risking Vulnerability was composed of Pushing Back, Working Through Team Relationships and Struggling with Inhumanity.

CONCLUSION

Healthcare professionals' moral agency occurred at the nexus of structure (organizational constraints) and agency (persons). Given this, interventions for MD should be directed at all levels of healthcare to support moral agency, promote ethical practice and improve care.

IMPACT

Sociopolitical elements such as austerity measures undermined ethical practice at the level of direct care. Enactment of moral agency is dynamic, influencing experiences of MD: participants supported by leadership or colleagues to enact moral agency noted that they were not stuck in MD. Interventions supporting moral agency throughout the healthcare system are necessary to mitigate experiences of MD. Findings enhance our understanding of the role of action in the experience of MD.

Understanding the relevance of human rights in healthcare and nursing practice

While the NHS aims to respect the human rights of every individual, it also has a wider social duty to promote equality in the services it provides. This means that the rights of individual patients are not absolute, because the aim of the NHS is to improve the overall health and well-being of the nation. For example, certain treatments may be withheld from individuals because of the excessive cost to the NHS, or concerns about its clinical effectiveness. This article explains the origins of human rights and their function, and examines the relationship between nursing care and human rights.

The Law, Ethics and Body Donation: A Tale of Two Bequeathal Programs

Historically, legislature has been utilized to facilitate appropriate use of cadavers in the anatomical sciences. However, cadaver acquisition and use have also been guided by ethically appropriate and morally acceptable principles. Various global and regional frameworks of "ethical practice" guide body donation, including the use of unclaimed bodies by institutions. These frameworks are responsive to, and reciprocal with the various ethical, moral and legal factors that influence the development of body donation programs. This reciprocity supports the notion that anatomists and anatomical societies have a responsibility to advocate for legal reform when required. In this study, two body bequest programs from geopolitically and socially disparate countries are used as cases to contrast existing legal and governance frameworks for body donation and to examine whether anatomists can direct the acquisition of ethically donated cadavers. The study includes an Australian donor program that has exclusively accepted bequests since its inception, and a South African program that has recently transitioned to a bequest system. Elements such as consent by next-of-kin and Inspector of Anatomy, use of unclaimed bodies and ethics committee approval amongst others, are compared. It is acknowledged that legal frameworks for cadaver acquisition generally deliver broad guidance on acceptable utilization of bodies for the anatomical sciences. However, professional discretion is of importance in adapting to societal needs and values. Thus, while anatomists have been able to progress toward more ethical practice than that which is required by the law, they must continue to do so as societal values evolve.

Exploring the experiences of domiciliary caregivers simulating the role of care recipients

AIM

To find out if an immersive simulation intervention would be feasible in a domiciliary care context, and to explore what effect, if any, the intervention would have on the domiciliary caregivers who participated.

METHOD

This was an immersive simulation pilot project in which six domiciliary caregivers (simulants) assumed the profile of people receiving domiciliary care. Second-year and third-year nursing students provided domiciliary care to the simulants, with support from a registered nurse. Thematic analysis was used to identify themes from post-intervention semi-structured interviews and a focus group with the simulants.

FINDINGS

Five main themes were identified: recognising the need for stimulation; reflecting on the importance of person-centred communication; the value of companionship and confidence in caregivers; understanding boundaries and vulnerabilities; and empathy and practice changes. Following the intervention, most of the simulants reported that they re-examined the care they provide from the care recipient's perspective, and were increasingly attuned to the wishes of care recipients.

CONCLUSION

The findings of this pilot project suggest that immersive simulation could be a valuable intervention in the domiciliary care context. The feedback from simulants suggests that it is beneficial to provide domiciliary caregivers with the opportunity to assume the role of care recipients, and enables them to reflect on the complexity and value of the care that they provide. The findings indicate that important elements of ethical care include domiciliary caregivers having adequate time to deliver care and develop trust, which can assist in fostering effective caregiver-care recipient relationships.

Sand in the Shorts: Experiences of Moral Discomfort in Adapted Physical Activity Professional Practice

Adapted physical activity (APA) practitioners are encouraged to be reflexive practitioners, yet little is known about the moral dilemmas faced as they instruct inclusive physical activity or fitness programs. Professional landscape tensions may arise when diverse organizational demands, policies, traditions, and values merge. The study purpose was to explore how APA professionals experience and resolve moral discomfort in professional practice. Using interpretative phenomenological analysis, seven APA professionals completed one-on-one semistructured interviews. The conceptual framework of relational ethics facilitated deep engagement with the professionals' stories of navigating the ethical minefields of their practice. Four themes were developed from the thematic interpretative phenomenological analysis: The ass(et) of vulnerability, Friends or friendly? "We are fucked either way," and Now what? Grappling with discomfort. The moral discomfort and strategies for resolution described by APA professionals highlighted the need for judgment-free pedagogical spaces where taken-for-granted practices can be contemplated and discussed.

Withdrawal of treatment from critically ill children: legal and ethical issues

Withdrawal of treatment from critically ill children is a contentious and ethically difficult area. The principle of best interests was central to three recent high-profile legal cases and raised questions about how this is demonstrated in healthcare for children whose treatment may be of no benefit to them. This article discusses the legal and ethical aspects of caring for such children. Nurses are important advocates and should balance their obligation to deliver holistic and family-centred care with that of keeping the child as the central focus, particularly with decision-making. In cases of disagreement between families and clinicians, children's voices are particularly vulnerable to being lost. Pre- and post-registration education, research and a higher profile for nurses in multidisciplinary decision-making are suggested as ways to improve the nursing contribution to this important debate.

In the child's best interests: should life be sustained when further treatment is futile?

The aim of this article is to explore the concept of medical futility and the withdrawal of care for children in intensive care units. There have been several recent cases where medical staff have considered that there was no possibility of recovery for a child, yet their clinical judgments were challenged by the parents. The private anguish of these families became public, social media heightened emotions and this was followed by political and religious intrusion. Innovations in medical treatment and technological advances raise issues for all those involved in the care of children and young people especially when decisions need to be made about end of life care. Healthcare professionals have a moral and legal obligation to determine when treatment should cease in cases where it is determined to be futile. The aim should be to work collaboratively with parents but all decisions must be made in the best interests of the child. However, medical staff and parents may have differing opinions about care decisions. In part, this may be as a result of their unique relationships with the child and different understanding of the extent to which the child is in discomfort or can endure pain.

Looking, But Not Listening? Theorizing the Practice and Ethics of Online Ethnography

There are debates across disciplines regarding how to research and represent digital cultures ethically. Against this background, there is a need to reflect on the practice and ethics of online ethnography. Ambiguities surrounding researcher "participation" online have led this to be equated largely with observation. This has deprivileged the act of listening in both research practice and the methodological and ethical debates that underpin this. Utilizing ethnographic research into self-harm and social media as a critical lens, this article advocates for listening as a mode of participating in, as well as observing, online spaces. In proposing "active listening" and "adaptive listening" to explore the polyphonic and heterogeneous nature of social media, we argue that listening is key to representing online spaces in all their cultural diversity and emotional complexity. Reflecting on listening is necessary to forging a practical ethics of online ethnography, and is relevant to digital research more widely.

Ethical practice in dementia care

This article draws on a range of case study examples from dementia care and explains how ethical theory can be applied to enhance professional practice. Ethical concepts are critically examined in this context and tensions between them are explored. The article demonstrates how an established ethical framework can assist with application in practice situations. It also argues that cultivating virtues, such as courage and receptivity, is an essential aspect of providing ethical nursing care for people with dementia.

Promoting Civility in the OR: An Ethical Imperative

Recognizing, addressing, and preventing incivility in the health care environment, including the perioperative area, requires an intentional and informed approach to foster healthy workplaces and protect patient safety. Several important foundational documents and position statements speak directly to the nurse's responsibility to protect patient, coworker, and personal safety and promote civility and respect. In the complex, fast-paced environment of the OR, the pressure to meet patient needs, performance outcomes, and patient safety standards can lead to conflict and incivility. In this article, we present a case-based scenario to illustrate a multilevel evidence-based response to an uncivil encounter that could negatively affect patient safety in the OR. After the scenario, we discuss the responses to the encounter from the organization, the nurse manager, and the individual nurse. When nurses speak up and resolve issues, they report better patient outcomes, greater satisfaction in the workplace, and heightened organizational commitment.

Caregivers' perspectives on ethical aspects of residential and domiciliary care

Aim To explore caregivers' perspectives on ethics in older people's residential and domiciliary social care. Method Seventeen staff working in domiciliary and residential care were divided into four focus groups and invited to share their perspectives on 'ethical' or 'good' care, the ethical issues that arise in their care practice, and barriers and enablers for ethical care. Findings A thematic analysis identified four themes: negotiating relationships, boundaries and the management of emotions, the effects of negative portrayals of care, and becoming a good carer. Conclusion Providing ethical social care is complex, and involves managing emotional boundaries and relational issues. The authors suggest that caregivers provide skilled companionship to those in their care.

Antimicrobials in animal agriculture: parables and policy

In addition to the scientific, economic, regulatory and other policy factors that impact on antimicrobial decision-making in different jurisdictions around the world, there exist ethical, social and cultural bases for the contemporary use of these products in animal agriculture. Thus, the use of the word 'parable' to describe the contemporary moral stories that help to guide ethical antimicrobial use practices and broader policy decisions in animal agriculture is appropriate. Several of these stories reflect difficult decisions that arise from conflicting moral imperatives (i.e. both towards animal welfare and towards human health). Understanding the factors that combine to define the past and present paradigms of antimicrobial usage is crucial to mapping a path forward. There exist barriers, as well as opportunities, for advancing scenarios for reducing antimicrobial usage under a variety of voluntary, regulatory and legal policy frameworks. Any new approaches will ideally be structured to extend the use of present-day antimicrobials into the future, to provide novel alternatives for regulating any newly introduced antimicrobial products so as to maximize their useful life span and to ensure the optimal use of these products in animal agriculture to protect not only the health of animals and the interests of animal health/agriculture stakeholders, but also the human health and the interests of the public at large. A full range of policy approaches, which span the realm from strictly enforced regulations and laws to voluntary guidelines and compliance, should be explored with respect to their risks and benefits in a variety of worldwide settings and in full consideration of a range of stakeholder values.

Is it acceptable to destroy or include human embryos before day 5 in research programmes?

Day-3 poor-quality embryos (PQE) from IVF-embryo transfer cycles are usually destroyed or are included in research programmes. Knowing that these embryos have the ability to evolve to the blastocyst stage and yield embryonic stem cell lines, this study postulated that they could also give rise to live births. This is a prospective study including 186 IVF-embryo transfer candidates who had obtained at least one supernumerary PQE on day 3. PQE were kept for extended culture and high-quality blastocysts were frozen. A total of 620 PQE were eligible for the study, 217 (35.0%) reached the blastocyst stage and 73 (33.6%) were frozen. Blastulation rates were 7-fold higher (OR 7.29, 95% CI 5.01-10.61) in embryos compacted on day 4. Of the frozen blastocysts, 40 were thawed during 33 thawed blastocyst transfer cycles, which led to 10 clinical pregnancies. These pregnancies resulted in five miscarriages and five healthy live births at full term. PQE may achieve their development to the blastocyst stage, be frozen-thawed and harbour reasonable implantation potential. These results, thereby, raise an ethical issue regarding the fate reserved to PQE.

Framing the issues: moral distress in health care

Moral distress in health care has been identified as a growing concern and a focus of research in nursing and health care for almost three decades. Researchers and theorists have argued that moral distress has both short and long-term consequences. Moral distress has implications for satisfaction, recruitment and retention of health care providers and implications for the delivery of safe and competent quality patient care. In over a decade of research on ethical practice, registered nurses and other health care practitioners have repeatedly identified moral distress as a concern and called for action. However, research and action on moral distress has been constrained by lack of conceptual clarity and theoretical confusion as to the meaning and underpinnings of moral distress. To further examine these issues and foster action on moral distress, three members of the University of Victoria/University of British Columbia (UVIC/UVIC) nursing ethics research team initiated the development and delivery of a multi-faceted and interdisciplinary symposium on Moral Distress with international experts, researchers, and practitioners. The goal of the symposium was to develop an agenda for action on moral distress in health care. We sought to develop a plan of action that would encompass recommendations for education, practice, research and policy. The papers in this special issue of HEC Forum arose from that symposium. In this first paper, we provide an introduction to moral distress; make explicit some of the challenges associated with theoretical and conceptual constructions of moral distress; and discuss the barriers to the development of research, education, and policy that could, if addressed, foster action on moral distress in health care practice. The following three papers were written by key international experts on moral distress, who explore in-depth the issues in three arenas: education, practice, research. In the fifth and last paper in the series, we highlight key insights from the symposium and the papers in the series, propose to redefine moral distress, and outline directions for an agenda for action on moral distress in health care.