Nurturing moral community: A novel moral distress peer support navigator tool

Moral distress is a pervasive phenomenon in healthcare for which there is no straightforward "solution." Rhetoric surrounding moral distress has shifted over time, with some scholars arguing that moral distress needs to be remedied, resolved, and eradicated, while others recognize that moral distress can have some positive value. The authors of this paper recognize that moral distress has value in its function as a warning sign, signaling the presence of an ethical issue related to patient care that requires deeper exploration, rather than evidencing identification of the "right" course of action. Once the experience of moral distress is identified, steps ought to be taken to clarify the moral issue, and, if possible and reasonable, the patient's values ought to be prioritized. This paper offers concrete actions steps, drawn from theory, which can be used in clinical practice to provide peer support or to facilitate self-reflection for morally distressed individuals. This approach empowers morally distressed individuals to explore ethical issues, identify concrete steps that can be taken, and mitigate feelings of powerlessness that are often associated with moral-constraint distress. The questions guide individuals and peers to reflect first on the micro-space and then more broadly on the institutional culture, facilitating meso- and macro-reflection and action.

Truth-telling to the seriously ill child - Nurses' experiences, attitudes, and beliefs

BACKGROUND

Nurses play an integral role in the care of children hospitalised with a serious illness. Although information about diagnostics, treatments, and prognosis are generally conveyed to parents and caregivers of seriously ill children by physicians, nurses spend a significant amount of time at the child's bedside and have an acknowledged role in helping patients and families understand the information that they have been given by a doctor. Hence, the ethical role of the nurse in truth disclosure to children is worth exploring.

METHODS

A systematic academic database and grey literature search strategy was conducted using CINAHL, Medline Psych Info, and Google Scholar. Keywords used included truth, children, nurse, disclosure, serious illness, and communication. A total of 17 publications of varying types were included in the final data set.

ETHICAL CONSIDERATIONS

As this was a review of the literature, there were no direct human participants. Empirical studies included in the review had received ethics approval.

RESULTS

Of the 17 articles included in the review, only one directly reported on the experiences of nurses asked to withhold the truth from patients. Empirical studies were limited to HIV-positive children and children diagnosed with cancer and the dying child.

CONCLUSION

A paucity of literature exploring the experiences, attitudes, and beliefs of nurses with regard to truth-telling to seriously ill children is evident. Little consideration has been given to the role nurses play in communicating medical information to children in a hospital setting. The 17 articles included in the review focused on cancer, and HIV, diagnosis, and end-of-life care. Further research should be undertaken to explore the experiences and attitudes of nurses to clinical information sharing to children hospitalised with a wide range of serious illnesses and in diverse clinical scenarios.

Use of the Rasch Model for Fit Statistics and Rating Scale Diagnosis for the Student Perception Appraisal-Revised

Background and Purpose: Nursing student retention is essential to meet workforce demands. Jeffrey's Nursing Student Retention Student Perception Appraisal-Revised (SPA-R1) has been used extensively to understand factors that impact retention. Psychometric testing of the SPA-R1 contributes to greater confidence in the instrument's reliability and validity. Methods: Item response theory and specifically, the single parameter polytomous Rasch model was used as a framework for fit statistic testing and rating scale diagnostics of the SPA-R1. This was a secondary analysis of a convenience sample of undergraduate prelicensure nursing students. The setting for the previous study was virtual, and the study period was 2022. Results: The model item characteristic curves for the 27 items of the SPA-R1 have similar shapes and are clustered in proximity. Overall, there are three clusters of items evident in the Rasch standardized residual contrast. The Rasch scale diagnostics indicated that the scale appropriately monotonically increases. However, there is a greater than 5 logit distance between does not apply and severely restricts, between severely restricts and moderately restricts, and between does not restrict or support and moderately supports. These large threshold distances indicate that additional steps in the scale may be warranted. The items cover the mid-range of the amount of retention perceptions; however, there are no items that represent the highest magnitude of the perceived amount of influence on retention. Conclusions: This study contributes further evidence to support the validity and reliability of the SPA-R1. We recommend adding steps to the scale, removing the does not apply response option, and considering scoring by three domains or clusters.

Midwifery students' experiences: Violations of dignity during childbirth

BACKGROUND

The principle of human dignity is woven into the ethical principles of the midwifery profession, noted as both an obligation and a human right.

RESEARCH OBJECTIVES

The aim of this study is to explore the experiences of midwifery students regarding threats to women's dignity during childbirth.

RESEARCH DESIGN

This is a qualitative study with explorative design. Participants and Research Context: The research was carried out in 2022 at Kermanshah University of Medical Sciences, involving 32 midwifery students in individual interviews that lasted between 30 and 90 minutes. These participants aged 21 to 28 years, with an average age of 23.5 years, provided their perspectives on the matter.

RESULTS

Four key themes described the threats to women's dignity during childbirth: 1) professional incompetence, 2) abuse of power imbalance, 3) caring only for physical and not mental health, and 4) structural issues within the healthcare system. Professional incompetence was characterized by outdated practices and lack of adherence to evidence-based medicine. Abuse of power imbalance was demonstrated in instances where the authoritative position of healthcare providers was misused, thereby disrupting the respectful care that women are entitled to receive. The disproportionate emphasis on physical health over mental health was evidenced by the disregard for mothers' psychological well-being during childbirth. Lastly, systemic structural issues emerged as significant impediments, revealing the need for system-wide changes. Ethical considerations: This study was approved by the Ethics Committee of the Research Deputy at Kermanshah University. Participation was voluntary and the confidentiality were maintained.

CONCLUSION

The findings underscore the role that unprofessional behavior, ethical lapses in medical practices, and systemic challenges play in undermining maternal dignity during childbirth. These threats necessitate urgent attention and must be adequately addressed in policy development and program implementation to safeguard the dignity of mothers during childbirth.

Validity and Reliability Evidence of the Munro Scale for Perioperative Patients Part II: Construct Validity

Background and Purpose: The Munro Pressure Injury Risk Assessment Scale for Perioperative Patients (Munro Scale) is the first three-phase risk instrument designed specifically for perioperative patients. The purpose of this study was to establish validity and reliability evidence for the Munro Scale. This study also had a goal to reduce the data into more manageable constructs with fewer items. Methods: Exploratory and confirmatory factor analyses were used to test the hypothesized model for risk assessment using the Munro Scale to identify latent variables. A retrospective review of charts from 630 risk assessments was analyzed from two community acute care hospital settings. Results: The model explained 95% of the variance in the cumulative final risk level, R² = .95, F(20, 588) = 501.88, p < .001. Six latent variables emerged in the model with a cumulative contribution rate of 56% of the variance. Similar results were obtained in studies with Chinese and Turkish translations of the Munro Scale. Conclusions: The validity and reliability evidence obtained in this study supports the implementation of the Munro Scale for clinical practice in the perioperative setting.

Moral distress in clinical research nurses

Background: Clinical research nurses experience unique challenges in the context of their role that can lead to conflict and moral distress. Although examined in many areas, moral distress has not been studied in clinical research nurses.Research aim: The aim of this study was to examine moral distress in clinical research nurses and the relationship between moral distress scores and demographic characteristics of clinical research nurses.Research design: This was a descriptive quantitative study to measure moral distress in clinical research nurses using the Measure of Moral Distress - Healthcare Professionals (MMD-HP) administered electronically. Demographic data were also collected.Participants and research context: Registered nurses working in the clinical research nurse role (N = 322) were recruited through use of social media, emails, digital flyers, and snowball recruitment. Data was analyzed using SPSS. Pearson's correlation, independent t-test, and one-way ANOVA were performed to explore differences among the demographic variables.Ethical considerations: This study was approved by the Institutional Review Board at Texas Woman's University. A consent statement was included, and completion of the questionnaire was construed as consent.Findings/results: Analysis revealed a mean overall moral distress score of 79.58 (SD = 64.27) and median of 67, with a range of 0-354. Moral distress scores were negatively correlated with clinical research nurse age (r = 0-.156, p < 0.05). Reliability of the MMD-HP was demonstrated with a Cronbach's alpha of 0.93.Conclusions: The findings demonstrate that clinical research nurses do experience moral distress and revealed a wide range of scores. Further research is necessary to determine potential patient impact due to moral distress and to develop processes to minimize moral distress in the clinical research setting. This study was conducted during the COVID-19 pandemic, and the digital recruitment methods proved effective in recruiting a wide range of clinical research nurses, both nationally and internationally.

Multidisciplinary support for ethics deliberations during the first COVID wave

BACKGROUND

The first COVID-19 wave started in February 2020 in France. The influx of patients requiring emergency care and high-level technicity led healthcare professionals to fear saturation of available care. In that context, the multidisciplinary Ethics-Support Cell (EST) was created to help medical teams consider the decisions that could potentially be sources of ethical dilemmas.

OBJECTIVES

The primary objective was to prospectively collect information on requests for EST assistance from 23 March to 9 May 2020. The secondary aim was to describe the Cell's functions during that period.

RESEARCH DESIGN

This observational, real-time study of requests for Cell consultations concerned ethical dilemmas arising during a public health crisis. The EST created a grid to collect relevant information (clinical, patient's/designated representative's preferences and ethical principles strained by the situation), thereby assuring that each EST asked the same questions, in the same order.

PARTICIPANTS AND RESEARCH CONTEXT

Only our university hospital's clinicians could request EST intervention.

ETHICAL CONSIDERATIONS

The hospital Research Ethics Committee approved this study (no. CER-2020-107). The patient, his/her family, or designated representative was informed of this ethics consultation and most met with EST members, which enabled them to express their preferences and/or opposition.

FINDINGS/RESULTS

33 requests (patients' mean age: 80.8 years; 29 had COVID-19: 24 with dyspnea, 30 with comorbidities). 17 Emergency Department solicitations concerned ICU admission, without reference to resource constraints; others addressed therapeutic proportionality dilemmas.

DISCUSSION

Intervention-request motives concerned limited resources and treatment intensity. Management revolved around three axes: the treatment option most appropriate for the patient, the feasibility of implementation, and dignified care for the patient.

CONCLUSIONS

COVID-19 crisis forced hospitals to envisage prioritization of ICU access. Established decision-making criteria and protocols do not enable healthcare professionals to escape ethical dilemmas. That acknowledgement highlights ethical risks, enhances the added-value of nursing and encourages all players to be vigilant to pursue collective deliberations to achieve clear and transparent decisions.

Experiences of critical care nurses during the early months of the COVID-19 pandemic

BACKGROUND

Critical care nurses have risked their lives and in some cases their families through hazardous duty during the COVID-19 pandemic and have faced multiple ethical challenges.

RESEARCH/AIM

The purpose of our study was to examine how critical care nurses coped with the sustained multi-faceted pressures of the critical care environment during the unchartered waters of the COVID-19 pandemic. It was anticipated that our study might reveal numerous ethical challenges and decision points.

RESEARCH DESIGN

A qualitative descriptive study, utilizing an interpretivist paradigm.

PARTICIPANTS AND RESEARCH SETTING

Critical care nurses, working in either intensive care units or emergency departments (N = 11) who were primarily from Northern California hospitals. Individual in-depth ZOOM® session interviews, guided by semi-structured questions, were used to collect data. Interviews lasted between 18 and 59 min, with an average length of 33 min. Session interviews were transcribed and analyzed.

ETHICAL CONSIDERATIONS

This study was approved by the researchers' university Institutional Review Board.

FINDINGS

Five main themes emerged: Fear of the Unknown, Adapting to Practice Changes and Challenges, Patient Advocacy and Moral Distress, Isolation and the Depersonalization of Care, and Professionalism and a Call to Duty.

DISCUSSION AND CONCLUSION

Fear of becoming ill or bringing COVID-19 home to their families was a constant source of anxiety for nurses. There were numerous changes in policy and challenges to standard practice protocols, including most notably shortages in personal protective equipment, which nurses navigated resourcefully. Most nurses interviewed were motivated by a sense of professional duty. The nurses experienced some moral distress in their inability to advocate as they might like for their patients, especially at end of life. Infection control requirements for isolation.

Dignity and attitudes to aging: A cross-sectional study of older adults

Background: Dignity is a multidimensional construct that includes perception, knowledge, and emotions related to competence or respect. Attitudes to aging are a comprehensive personal view of the experience of aging over the course of life, which can be influenced by various factors, such as the levels of health and self-sufficiency and social, psychological, or demographic factors. Aim: The purpose of this study was to explore the attitudes to aging of home-dwelling and inpatient older adults, and whether dignity and other selected factors belong among the predictors influencing attitudes to aging in these two different groups of older adults. Research design: Cross-sectional study using a set of questionnaires: Patient Dignity Inventory, Attitudes to Aging Questionnaire, and Barthel Index. Pearson and Spearman correlation analyses and multivariable linear regression were used for statistical processing. Participants and research context: 233 inpatients and 237 home-dwelling older adults participated in the research in two regions of the Czech Republic. Ethical considerations: Institutional Review Board approval was received from the authors’ university. Findings: The inpatients had more negative attitudes to aging (M = 74.9±10.9; P <0.0001). The predictors of their attitudes to aging were gender and dignity. Women (β = −2.969, P = 0.045) and inpatients with poor dignity ratings (β = −0.332, P <0.0001) had more negative attitudes to aging. The predictors for home-dwelling older adults were education, living arrangement, and dignity. More negative attitudes to aging were found in older adults with lower levels of education (β = 2.716, P = 0.007) who lived alone (β = 2.163, P = 0.046) and rated their dignity as low (β = −0.325, P <0.0001). Discussion and Conclusions: The results of this study add to the understanding that a sense of dignity is an important predictor of attitudes to aging for both home-dwelling older adults and inpatients.

Dignity of older home-dwelling women nearing end-of-life: Informal caregivers' perception

BACKGROUND

Most older people wish to live in the familiar surroundings of their own home until they die. Knowledge concerning dignity and dignity loss of home-dwelling older women living with incurable cancer should be a foundation for quality of care within municipal healthcare services. The informal caregivers of these women can help increase the understanding of sources related to dignity and dignity loss.

AIM

The aim of this study was to explore informal caregivers' perceptions of sources related to dignity and dignity loss in end-of-life of older home-dwelling women with incurable cancer.

RESEARCH DESIGN AND METHOD

The study was founded upon Gadamer's philosophical hermeneutics. In-depth interviews with 13 informal caregivers were carried out, and four participant observations were performed during home meetings.

ETHICAL CONSIDERATION

The study was based on voluntary participation, informed consent, confidentiality and the opportunity to withdraw at any time. The Norwegian Social Science Data Services approved the study.

RESULTS

Three main sources important in preserving the older women's dignity were identified: maintaining one's self-concept, remaining hopeful and sustaining freedom of choice. We also identified three main sources that lead to dignity loss: Sensing loss of human value, experiencing absence of gentleness and feelings of being treated as an object.

DISCUSSION AND FINAL CONSIDERATIONS

On the individual level, the opportunity to maintain one's self-concept and control in life, preserved dignity, while feelings of existential loneliness led to dignity loss. On the relational level, being confirmed as worthy human beings promoted the women's dignity, whereas dignity loss was related to uncaring behaviours from healthcare professionals. On the societal level, individual decisions concerning travel situations and the place to stay when nearing end-of-life were of crucial importance. Constituting these women's living space, these perspectives should be emphasized in healthcare professionals' educational training and in the municipal end-of-life care of these patients.

Processes toward the end of life and dialysis withdrawal Physicians' and nurses' perspectives

BACKGROUND

Nurses and physicians in nephrology settings provide care for patients with end-stage kidney disease receiving hemodialysis treatment along a complex illness trajectory.

AIM

The aim was to explore physicians' and nurses' perspectives on the trajectories toward the end of life involving decisions regarding hemodialysis withdrawal for patients with end-stage kidney disease.

RESEARCH DESIGN AND PARTICIPANTS

A qualitative research approach was used. Four mixed focus group interviews were conducted with renal physicians (5) and nurses (17) in Sweden. Qualitative content analysis was used to analyse data.

ETHICAL CONSIDERATIONS

Ethical approval was obtained (Dnr 2014/304-31).

FINDINGS AND DISCUSSION

Findings illuminated multi-faceted, intertwined processes encompassing healthcare professionals, patients, and family members. The analysis resulted in four themes: Complexities of initiating end-of-life conversations, Genuine attentiveness to the patient's decision-making process, The challenge awaiting the family members' processes, and Negotiating different professional responsibilities. Findings showed complexities and challenges when striving to provide good, ethical care which are related to beneficence, nonmaleficence, and self-determination, and which can give rise to moral distress.

CONCLUSION

There are ethical challenges and strains in the dialysis context that healthcare professionals may not always be prepared for. Supporting healthcare professionals in not allowing complexities to hinder the patient's possibilities for shared decision-making seems important. An open and continual communication, including family meetings, from dialysis initiation could serve to make conversations involving decisions about hemodialysis withdrawal a more natural routine, as well as build up a relationship of trust necessary for the advance care planning about the end of life. Healthcare professionals should also receive support in ethical reasoning to meet these challenges and handle potential moral distress in the dialysis context.

Opinions of nurses regarding conscientious objection

BACKGROUND

In the last decades, there have been important developments in the scientific and technological areas of healthcare. On certain occasions this provokes conflict between the patients' rights and the values of healthcare professionals which brings about, within this clinical relationship, the problem of conscientious objection.

AIMS

To learn the opinions that the Nurses of the Madrid Autonomous Community have regarding conscientious objection.

RESEARCH DESIGN

Cross-cutting descriptive study.

PARTICIPANTS AND RESEARCH CONTEXT

The nurses of 9 hospitals and 12 Health Centers in the Madrid Autonomous Community. The study was done by means of an auto completed anonymous questionnaire. The variables studied were social-demographical and their opinions about conscientious objections.

ETHICAL CONSIDERATIONS

The study was approved by the Ethical Community of Clinical Research of the University Hospital Príncipe de Asturias. Participants were assured of maximum confidentiality and anonymity.

FINDINGS

A total of 421 nurses answered the questionnaire. In total, 55.6% of the nurses confirmed they were religious believers, and 64.3% declared having poor knowledge regarding conscientious objection. The matters that caused the greatest objections were voluntary abortions, genetic embryo selection, refusal of blood transfusions, and therapy refusal.

DISCUSSION

Different authors state that the most significant cases of conscientious objections for health professionals are those regarding carrying out or assisting in abortions, euthanasia, the practice of assisted reproduction and, finally, the prescription and dispensing of the morning-after pill. In our study, the most significant cases in which the nurses would declare conscientious objections would be the refusal to accept treatment, the selection of embryos after genetic diagnosis preimplantation, the patient's refusal to receive blood transfusions due to religious reasons and pregnant women's request for voluntary abortions within the first 14 weeks.

CONCLUSION

Nurses' religious beliefs influence their opinions regarding conscientious objection. The nurses who declare themselves as religious believers object in a higher percentage than those without religious beliefs.

Ethical decision-making levels of oncology nurses

AIM

This study was carried out in order to determine ethical decision-making levels of oncology nurses.

ETHICAL CONSIDERATION

Research Ethics Committee's approval was obtained prior to the data collection. Permission to use the Turkish version of the Nursing Dilemma Test was received from Birgül Cerit. Written approval was taken from school administrators to conduct the study confirming that there were no invasive procedures planned for human beings during the study period. The study was conducted in accordance with the Helsinki Declaration. Verbal consent was obtained from each of the nurses who agreed to participate after they were informed about the study content.

METHOD

The population of this study conducted in a descriptive way consisted of a total of 96 nurses working at the oncology units and outpatient chemotherapy units of four different hospitals between September 2017 and March 2018. The study sample included 60 nurses who responded to the question form. The data of the study were collected using "Nurses Information Questionnaire" and "Nursing Dilemma Test" developed by Crisham in 1981.

RESULTS

Oncology nurses' mean scores in Principled Thinking (49.00 ± 6.46) and those in Practical Considerations (18.35 ± 4.47) were found to be above the moderate level. It was determined that the oncology nurses participated in the study were familiar with situations similar to the dilemmas included in the Nursing Dilemma Test (15.00 ± 4.20).

CONCLUSION

It was concluded that oncology nurses try to take ethical principles into consideration but are also affected by environmental factors while making decisions concerning ethical dilemmas. The most frequently encountered ethical dilemmas by oncology nurses include the following: deciding not to perform cardiopulmonary resuscitation, telling the truth to the patient, studies being carried out without the patient's content, and patient's refusal of treatment. In order to improve oncology nurses' critical thinking and ethical decision-making skills, it is important to determine ethical dilemmas encountered by oncology nurses, and nurses should be encouraged to be involved in ethical decision-making process through cooperation with the other healthcare personnel.

Conflict in the intensive care unit: Nursing advocacy and surgical agency

BACKGROUND

Nurses and surgeons may experience intra-team conflict during decision making about the use of postoperative life-sustaining treatment in the intensive care unit due to their perceptions of professional roles and responsibilities. Nurses have a sense of advocacy-a responsibility to support the patient's best interest; surgeons have a sense of agency-a responsibility to keep the patient alive.

OBJECTIVES

The objectives were to (1) describe the discourse surrounding the responsibilities of nurses and surgeons, as "advocates" and "agents," and (2) apply these findings to determine how differences in role responsibilities could foster conflict during decision making about postoperative life-sustaining treatment in the intensive care unit.

RESEARCH DESIGN

Articles, books, and professional documents were explored to obtain descriptions of nurses' and surgeons' responsibilities to their patients. Using discourse analysis, responsibilities were grouped into themes and then compared for potential for conflict. Ethical considerations: No data were collected from human participants and ethical review was not required. The texts were analyzed by a surgeon and a nurse to minimize profession-centric biases.

FINDINGS

Four themes in nursing discourse were identified: responsibility to support patient autonomy regarding treatment decisions, responsibility to protect the patient from the physician, responsibility to act as an intermediary between the physician and the patient, and the responsibility to support the well-being of the patient. Three themes in surgery discourse were identified personal responsibility for the patient's outcome, commitment to patient survival, and the responsibility to prevent harm to the patient from surgery.

DISCUSSION

These responsibilities may contribute to conflict because each profession is working toward different goals and each believes they know what is best for the patient. It is not clear from the existing literature that either profession understands each other's responsibilities.

CONCLUSION

Interventions that improve understanding of each profession's responsibilities may be helpful to reduce intra-team conflict in the intensive care unit.

Nurse leaders' role in medical assistance in dying: A relational ethics approach

Recent changes to the Criminal Code of Canada have resulted in the right of competent adult Canadians to request medical assistance in dying (MAID). Healthcare professionals now can participate if the individual meets specific outlined criteria. There remains confusion and lack of knowledge about the specific role of nurses in MAID. MAID is a controversial topic and nurses may be faced with the challenge of balancing the duty to provide routine care, with moral reservations about MAID. The role of a nursing leader is to support nurses by ensuring they have the knowledge they require to care for patients requesting the service, whether or not the nurse is directly involved in the MAID process. The moral dilemmas raised by MAID provide an opportunity to look at a relational ethics approach to nursing leadership both for MAID and other difficult situations that arise in nursing practice. Relational ethics is a framework that proposes that the ethical moments in healthcare are based on relationships and fostering growth, healing, and health through the foundational concepts of mutual respect, engagement, embodiment, and environment. This article will use a relational ethics framework to examine how nursing leadership can support nurses who care for patients requesting MAID.

Dignity in nursing care: What does it mean to nursing students?

BACKGROUND:

Despite growing interest in the potential of nursing education to enhance dignity in nursing care, relatively little is known about what dignity means to nursing students.

RESEARCH QUESTION:

What meaning does dignity in nursing care have for nursing students?

RESEARCH DESIGN:

Photo-elicitation was embedded within a Nominal Group Technique and responses were analysed by qualitative and quantitative content analysis.

PARTICIPANTS AND RESEARCH CONTEXT:

Participants were recruited from each year of a 3-year undergraduate preregistration adult nursing programme in Scotland. In total, 31 nursing students participated in the study.

ETHICAL CONSIDERATIONS:

The study was approved by the Ethics Committee of the School of Health, Nursing and Midwifery, University of the West of Scotland.

FINDINGS:

Participants articulated the meaning of dignity in nursing care in terms of the relationships and feelings involved. A total of 10 categories of meaning were identified.

DISCUSSION:

The significance of the nature of the nurse-patient interaction to preserving dignity in nursing care is highlighted.

CONCLUSION:

Understanding the meaning of dignity for nursing students may help prepare future nurses more able to preserve dignity in nursing care.

Patient's dignity in intensive care unit: A critical ethnography

BACKGROUND

Maintaining patient's dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units.

OBJECTIVES

The aim of this study was to uncover the cultural factors that impeded maintaining patients' dignity in the cardiac surgery intensive care unit.

RESEARCH DESIGN

The study was conducted using a critical ethnographic method proposed by Carspecken.

PARTICIPANTS AND RESEARCH CONTEXT

Participants included all physicians, nurses and staffs working in the study setting (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace.

ETHICAL CONSIDERATION

Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained.

FINDINGS

The findings of the study fell into the following main themes: "Presence: the guarantee for giving enough attention to patients' self-esteem", "Instrumental and objectified attitudes", "Adherence to the human equality principle: value-action gap", "Paternalistic conduct", "Improper language", and "Non-interactive communication". The final assertion was "Reductionism as a major barrier to the maintaining of patient's dignity".

DISCUSSION

The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches.

CONCLUSION

Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships.

Nurse researchers' perspectives on research ethics in China

BACKGROUND

In China, research ethics is a subject of increasingly formal regulation. However, little is known about how nursing researchers understand the concept of research ethics and the ways in which they can maintain ethical standards in their work.

AIM

The aim of this study is to examine nursing researchers' perspectives on research ethics in China.

RESEARCH DESIGN

We conducted a descriptive qualitative study. Qualitative research methods enabled us to gain an in-depth understanding of nursing researchers' views on research ethics.

PARTICIPANTS AND RESEARCH CONTEXT

We carefully selected and extensively interviewed 28 nursing researchers, nursing faculty, and clinical nurses who had been involved in research or who may undertake research in the future. We collected data between October 2014 and March 2015.

ETHICAL CONSIDERATIONS

This study was approved by the institutional review boards of Yale University and Central South University.

FINDINGS

We grouped the data into five categories based on the interviewees' responses: (1) perceptions of ethics, bioethics, and research ethics; (2) perception of the ethics review process; (3) perception of the function of institutional review boards; (4) the need for comprehensive ethical guidelines for future studies; and (5) ethical challenges faced by the interviewees.

DISCUSSION AND CONCLUSION

This study contributes new insights into nursing researchers' views on research ethics in China and finds considerable shortcomings in researchers' understanding and implementation of ethical principles. Intensive educational efforts are needed to provide nursing researchers, institutional review board members, and even study subjects with accurate and up-to-date information and guidance on research ethics. In addition, while Western research ethics theoretically have guided Chinese clinical research for several years, the ways in which nursing researchers have implemented these ethical standards highlight the differences between the Eastern and Western ethical paradigms. This finding suggests the need for ethical standards that are more tailored to the Chinese context.

Dual loyalties: Everyday ethical problems of registered nurses and physicians in combat zones

BACKGROUND:

When healthcare personnel take part in military operations in combat zones, they experience ethical problems related to dual loyalties, that is, when they find themselves torn between expectations of doing caring and military tasks, respectively.

AIM:

This article aims to describe how Swedish healthcare personnel reason concerning everyday ethical problems related to dual loyalties between care and military tasks when undertaking healthcare in combat zones.

DESIGN:

Abductive qualitative design.

PARTICIPANTS AND RESEARCH CONTEXT:

Individual interviews with 15 registered nurses and physicians assigned for a military operation in Mali.

ETHICAL CONSIDERATIONS:

The participants signed up voluntarily, and requirements for informed consent and confidentiality were met. The research was approved by the Regional Ethics Review Board in Gothenburg (D no. 816-14; 24 November 2014).

FINDINGS:

Three main categories emerged: reasons for not undertaking combat duties, reasons for undertaking combat duties and restricted loyalty to military duties, and 14 subcategories. Reasons for not undertaking combat duties were that it was not in their role, not according to ethical codes or humanitarian law or a breach towards patients. Reasons for undertaking combat duties were that humanitarian law does not apply or has to be treated pragmatically or that it is a case of force protection. Shortage of resources and competence were reasons for both doing and not doing military tasks. Under some circumstances, they could imagine undertaking military tasks: when under threat, if unseen or if not needed for healthcare duties.

DISCUSSION/CONCLUSION:

These discrepant views suggest a lack of a common view on what is ethically acceptable or not, and therefore we suggest further normative discussion on how these everyday ethical problems should be interpreted in the light of humanitarian law and ethical codes of healthcare personnel and following this, further training in ethical reflection before going on military operations.

An assessment of advance relatives approach for brain death organ donation

BACKGROUND:

Advance announcement of forthcoming brain death has developed to enable intensivists and organ procurement organisation coordinators to more appropriately, and separately from each other, explain to relatives brain death and the subsequent post-mortem organ donation opportunity.

RESEARCH AIM:

The aim was to assess how potentially involved healthcare professionals perceived ethical issues surrounding the strategy of advance approach.

RESEARCH DESIGN:

A multi-centre opinion survey using an anonymous self-administered questionnaire was conducted in the six-member hospitals of the publicly funded East of France regional organ and tissue procurement network called 'Prélor'.

PARTICIPANTS:

The study population comprised 460 physicians and nurses in the Neurosurgical, Surgical and Medical Intensive Care Units, the Stroke Units and the Emergency Departments.

ETHICAL CONSIDERATIONS:

The project was approved by the board of the Lorraine University Diploma in Medical Ethics and the Prélor Network administrators.

MAIN FINDINGS:

A slight majority of 53.5% of respondents had previously participated in an advance relatives approach: 83% of the physicians and 42% of the nurses. A majority of healthcare professionals (68%) think that the main justification for advance relatives approach is the comprehensive care of the dying patient and the research of his or her most likely opinion (74%). The misunderstanding of the related issues by relatives is an obstacle for 47% of healthcare professionals and 51% think that the answer given by the relatives regarding the most likely opinion of the person regarding post-mortem organ donation really corresponds to the person opinion in only 50% of the cases or less.

CONCLUSION:

Time given by advance approach should be employed to help and enable relatives to authentically bear the values and interests of the potential donor in the post-mortem organ donation discussion. Nurses' attendance of advance relatives approach seems necessary to enable them to optimally support the families facing death and post-mortem organ donation issues.

Prioritising patient care: The different views of clinicians and managers

BACKGROUND

There is little research comparing clinicians' and managers' views on priority settings in the healthcare services. During research on two different qualitative research projects on healthcare prioritisations, we found a striking difference on how hospital executive managers and clinical healthcare professionals talked about and understood prioritisations.

AIM

The purpose of this study is to explore how healthcare professionals in mental healthcare and somatic medicine prioritise their care, to compare different ways of setting priorities among managers and clinicians and to explore how moral dilemmas are balanced and reconciled. Research design and participants: We conducted qualitative observations, interviews and focus groups with medical doctors, nurses and other clinical members of the interdisciplinary team in both somatic medical and mental health wards in hospitals in Norway. The interviews were recorded and transcribed verbatim. Ethical considerations: Basic ethical principles for research ethics were followed. The respondents signed an informed consent for participation. They were assured anonymity and confidentiality. The studies were approved by relevant ethics committees in line with the Helsinki Convention.

FINDINGS

Our findings showed a widening gap between the views of clinicians on one hand and managers on the other. Clinicians experienced a threat to their autonomy, to their professional ideals and to their desire to perform their job in a professional way. Prioritisations were a cause of constant concern and problematic decisions. Even though several managers understood and empathised with the clinicians, the ideals of patient flow and keeping budgets balanced were perceived as more important.

DISCUSSION

We discuss our findings in light of the moral challenges of patient-centred individual healthcare versus demands of distributive justice from healthcare management.

CONCLUSION

The clinicians' ideals of autonomy and good medical and nursing care for the individual patients were perceived as endangered.

Is it morally permissible for hospital nurses to access prisoner-patients' criminal histories?

In the United States, information about a person's criminal history is accessible with a name and date of birth. Ruth Crampton has studied nurses' care for prisoner-patients in hospital settings and found care to be perfunctory and reactive. This article examines whether it is morally permissible for nurses in hospital settings to access information about prisoner-patients' criminal histories. Nurses may argue for a right to such information based on the right to personal safety at work or the obligation to provide prisoner-patients with the care that they deserve. These two arguments are considered and rejected. It is further argued that accessing information about a prisoner-patient's criminal history violates nurses' duty to care. Care, understood through Sarah Ruddick's account as work and relationship, requires nurses to be open and unbiased in order to do their part in forming a caring relationship with patients. Knowledge of a prisoner-patient's criminal history inhibits the formation of this relationship and thus violates nurses' duty to care.

Nurse participation in legal executions: An ethics round-table discussion

A paper was published in 2003 discussing the ethics of nurses participating in executions by inserting the intravenous line for lethal injections and providing care until death. This paper was circulated on an international email list of senior nurses and academics to engender discussion. From that discussion, several people agreed to contribute to a paper expressing their own thoughts and feelings about the ethics of nurses participating in executions in countries where capital punishment is legal. While a range of opinions were presented, these opinions fell into two main themes. The first of these included reflections on the philosophical obligations of nurses as caregivers who support those in times of great need, including condemned prisoners at the end of life. The second theme encompassed the notion that no nurse ever should participate in the active taking of life, in line with the codes of ethics of various nursing organisations. This range of opinions suggests the complexity of this issue and the need for further public discussion.

Addressing ethical concerns arising in nursing and midwifery students' reflective assignments

BACKGROUND

Written reflections on practice are frequently requirements of nursing curricula. They are widely accepted as necessary for improving critical thinking and problem-solving skills. Faculty, are expected to review reflections and provide feedback that helps professional development and facilitates good practice. It is less clear what the actions of nurse educators should be when ethical infractions are revealed in the narratives.

OBJECTIVES

We had two aims: 1) To combine insights from a literature review of empirical and theoretical research related to responding to ethical issues revealed in student reflections with our experiences reviewing the reflections of undergraduate nursing and midwifery students, and 2) to construct and analyze a hybrid case from these insights in order to develop guidelines for nurse educators.

RESEARCH DESIGN

A literature review was conducted using CINAHL, MEDLINE, PsycINFO, SocINDEX and ERIC databases and pertinent key words. A hybrid case was constructed of commonly encountered ethical issues using insights from the literature review and the authors' experiences. The case was analyzed by combining Beauchamp and Childress' principlist approach with Campbell and McCarthy's ethical decision-making tool (Table 1). Participants and Research Context: No human participants Findings: A gap in the literature exists related to addressing ethical issues revealed in student practice reflections. However, a combination of insights from the literature and the authors' experiences facilitated the development of a hybrid case. Subsequent case analysis facilitated the development of a series of guidelines that can be utilized to address a range of issues commonly emerging in the reflections of nursing students during practice experiences.

DISCUSSION

A number of recommendations and guidelines are provided to enable the safeguarding of students and staff and support them in practicing ethically.

CONCLUSION

Structured ethical analysis of a constructed hybrid reflection of commonly revealed ethical issues was useful in developing guidelines for educators.

Participants' safety versus confidentiality: A case study of HIV research

Background When conducting qualitative research, participants usually share lots of personal and private information with the researcher. As researchers, we must preserve participants' identity and confidentiality of the data. Objective To critically analyze an ethical conflict encountered regarding confidentiality when doing qualitative research. Research design Case study. Findings and discussion one of the participants in a study aiming to explain the meaning of living with HIV verbalized his imminent intention to commit suicide because of stigma of other social problems arising from living with HIV. Given the life-threatening situation, the commitment related to not disclosing the participant's identity and/or the content of the interview had to be broken. To avoid or prevent suicide, the therapist in charge of the case was properly informed about the participant's intentions. One important question arises from this case: was it ethically appropriate to break the confidentiality commitment? Conclusion confidentiality could be broken if a life-threatening event is identified during data collection and participants must know that. This has to be clearly stated in the informed consent form.

Nursing's professional respect as experienced by hospital and community nurses

BACKGROUND

There is growing awareness that patient care suffers when nurses are not respected. Therefore, to improve outcomes for patients, it is crucial that nurses operate in a moral work environment that involves both recognition respect, a form of respect that ought to be accorded to every single person, and appraisal respect, a recognition of the relative and contingent value of respect modulated by the relationships of the healthcare professionals in a determined context. Research question/aim: The purpose of this study was to develop better understandings of perceptions of nursing's professional respect in community and hospital settings in England.

RESEARCH DESIGN

The research design was qualitative. Focus groups were chosen as the most appropriate method for eliciting discussion about nursing's professional respect. Participants and research context: A total of 62 nurses who had been qualified for at least a year and were working in two localities in England participated in this study.

METHODS

Data were collected using 11 focus group sessions. The data were analysed by means of an inductive content analysis, extracting meaning units from the information retrieved and classifying the arising phenomena into conceptually meaningful categories and themes. Ethical considerations: To conduct the research, permission was obtained from the selected universities.

RESULTS

Recognition respect of human beings was perceived as ingrained in the innermost part of nurses. Regarding appraisal respect, a great importance was placed on: the interactions among healthcare professionals, the time to build trust in these relationships, the influences of the workplace characteristics and nurses' professional autonomy and decision-making.

CONCLUSION

Recognition respect of persons was embedded in the inmost part of nurses as individuals. Concerning appraisal respect, it was thought to be deeply enshrined in the inter- and intra-healthcare professional interactions. The forging of trusting relationships over time was deemed to be strongly associated with good quality interactions with other healthcare professionals.