This study examines the presence of ethical climates in skilled nursing facilities and identifies their antecedents (work group, job position, tenure). A cross-sectional survey design was implemented. A total of 359 facilities were selected in the Midwestern United States. Responses were received from nurses representing 100 of those facilities (28%). A total of 656 usable questionnaires were returned of the 3060 distributed (21.4% response rate). Descriptive statistics, confirmatory factor analysis, and multivariate and univariate analyses of variance (...) were used. The results confirmed the presence of five ethical climates. Significant differences between registered and licensed practical nurses with regard to egoistic and independence ethical climates were found. Furthermore, nurses in management and non-management positions differed significantly in their perceptions of caring and egoistic climates. The results suggest incongruence in value perceptions and imply that researchers and practitioners have to direct efforts towards preventing and identifying reasons behind this. (shrink)

ObjectivesThe study evaluated nurses’ perceptions on the benefits, drawbacks, and their roles in initiating and implementing advance directives at private and public secondary healthcare units.MethodsThe study adopted a cross-sectional, comparative-descriptive research design and was anchored on the structural functional theory. A total of 401 nurses were chosen on purpose. The data was collected between January and March 2018 among nurses at the selected hospitals. Analysis was done via SPSSv28.0.1.0.ResultsCompared to nurses working in private healthcare facilities, the majority of nurses (...) at the public healthcare facilities indicated a more favorable opinion of AD’s benefits and felt they had a substantial involvement in the development and execution of AD than their private counterpart. Similarly, 60.7% of nurses employed by the government agreed that AD has some disadvantages compared to those employed by the private sector. Significantly, Christian nurses are 0.53 times less likely than Muslims to contest AD’s benefits; 0.78 times less likely than Muslim to disagree that AD has flaws; and 1.30 times more likely than Muslim nurses to deny they contributed to the development and execution of AD, though not significant.ConclusionMaking decisions at the end-of-life can be challenging, thus AD should be supported across the board in the healthcare industry. Nurses should be trained on their role in developing and implementing AD, as well as on its advantages and how to deal with its challenges. (shrink)

Background:Ethical competence in nursing practice helps clinical nurses to think critically, analyse issues, make ethical decisions, solve ethical problems and behave ethically in their daily work. Thus, ethical competence contributes to the promotion of high-quality care. However, studies on ethical competence in Malawi are scanty.Objectives:The aim of this study was to explore ethical competence among clinical nurses in selected hospitals in Malawi.Methodology:A cross-sectional survey was conducted in four selected hospitals in Malawi with a sample of 271 clinical nurses. Data (...) were collected using self-administered questionnaires, which included a Moral Competence Scale for Home Care Nurses. Descriptive statistics and logistic regression were computed for the dataset using STATA version 12.0.Ethical consideration:The study protocol complied with all ethical requirements and was approved by the College of Medicine Research Ethics Committee under the University of Malawi.Results:The clinical nurses in Malawi are ethically competent. However, there is a significantly high number (p 0.05). Three determinants of high ethical competence level (strong will, judgement skills and recognition of discrepancy of intention) were identified through a reduced model after stepwise logistic regression analysis. Furthermore, results show that indicators of ethical competence include caring, confidentiality and observance of nurses dressing code. The study has also confirmed that the Moral Competence Scale for Home Care Nurses is a reliable tool to assess ethical competence in low-resource settings.Conclusion:The majority of nurses who completed the survey had low ethical competence. However, clinical nurses with high ethical competence level are required to competently manage complex ethical challenges in health facilities. Strategies for enhancing ethical competence such as continuing ethics education, establishment of ethics committees and provision of supportive supervision are recommended to enable nurses in Malawi attain a high level of ethical competence. (shrink)

Increased technological and pharmacological interventions in patient care when patient outcomes are uncertain have been linked to the escalation in moral and ethical dilemmas experienced by health care providers in acute care settings. Health care research has shown that facilities that are able to attract and retain nursing staff in a competitive environment and provide high quality care have the capacity for nurses to process and resolve moral and ethical dilemmas. This article reports on the findings of a (...) systematic review of the empirical literature (1980 — February 2007) on the effects of unresolved moral distress and poor ethical climate on nurse turnover. Articles were sought to answer the review question: Does unresolved moral distress and a poor organizational ethical climate increase nurse turnover? Nine articles met the criteria of the review process. Although the prevailing sentiment was that poor ethical climate and moral distress caused staff turnover, definitive answers to the review question remain elusive because there are limited data that confidently support this statement. (shrink)

Empirische Forschungsarbeiten zur Ethik im Gesundheitswesen können entsprechende Implementationsprojekte unterstützen. Inzwischen gibt es eine Vielfalt von Ethikberatungsansätzen und -strukturen, die jedoch noch nicht in allen Gesundheitseinrichtungen genutzt werden. Bedarfserhebungen können wichtige Daten zu Strategie- und Projekterfordernissen darstellen. Die Bedeutung und Gründe für die Einschätzung des Bedarfs an klinischer Ethikberatung werden in der Fachliteratur vielfach diskutiert. Im vorliegenden Beitrag werden die Ergebnisse aus der Literaturanalyse im Hinblick auf vorhandene Erhebungsinstrumente zusammengefasst und ein Konzept zur Entwicklung eines Bedarfserhebungsinstruments beschrieben. Das Konzept beinhaltet (...) Daten zum Erhebungsbereich, zu den Forschungsfragen, zur Zielformulierung und zu den Zielgruppen. Anschließend wird das vorläufig entwickelte Instrument kurz vorgestellt. Ziel des Erhebungsinstruments ist es zunächst, empirische Daten von handelnden Pflegepersonen zu erheben, um so eine Grundlage für den konkreten Unterstützungsbedarf zu erhalten. (shrink)

Among the collective as well as individual responsibilities of nurses as professionals is that of maintaining and improving the quality of nursing care. In exchange for monopoly status and professional authority to control nursing practice, the profession is charged with the responsibility of meeting the nursing care needs of the community. If one claims, as I do, that one of the collective responsibilities of nurses is maintenance of high nursing standards, we must examine what action is (...) required of nurses who find themselves in work contexts in which standards and practice are deficient. Specifically, is the strike weapon one that may or even ought to be used? In this essay, answers to the following two questions are advanced: (a) What conditions must obtain for it to be (morally) right for nurses in a particular health care facility to strike? (b) Does their collective responsibility with regard to nursing standards and practice ever entail that a group of nurses has a (moral) duty to strike? The essay concludes with a consideration of how one balances the collective responsibility to maintain and improve the quality of nursing care with an individual nurse's responsibility to her/his own patients. CiteULike Connotea Del.icio.us What's this? (shrink)

Nursing homes' ethics committees play a role in designing policies to assure ethical care. The administrative structure of nursing homes is not as large as that of hospitals. Nursing home staff and administration can respond to medical accidents in a way that treats family unethically and does serious harm to the facility. This paper describes incidents in which nursing homes attempted to conceal accidental deaths. It describes how such incidents are discovered, and the consequences of such (...) efforts, and suggests ways to prevent such incidents.This paper presents a retrospective review of a convenience sample of eight cases in which it was discovered that a nursing home attempted to conceal an accidental death. The effort to conceal an accidental death requires a coordinated effort to: [1] limit dissemination of information about the accident by staff and records, [2] decrease suspicion about the death, and [3] decrease the likelihood that an inquiry, if launched, will succeed. This effort begins as a reflexive, emotional and defensive response to the accident and consolidates as an institutional strategy to conceal both the accident and the concealment. The effort is coordinated by administrators who coerce cooperation from front line staff, alter medical records, and fail to follow reporting procedures. The attempt to conceal a lethal accident adversely affects the facility and the healthcare system. Ethics committees should work with professional organizations and administrator to assure proper management and disclosure of harmful accidents. (shrink)

Certified nursing assistants (CNAs) provide up to 80% of the direct care to older adults in long‐term care facilities.CNAs are perceived as being at the bottom of the hierarchy among healthcare professionals often negatively affecting their job satisfaction. However, manyCNAs persevere in providing quality care and even reporting high levels of job satisfaction. The aim of the present investigation was to identify primary themes that may helpCNAs make meaning of their chosen career; thus potentially partially explaining increases in (...) job satisfaction among this group. Focus groups were conducted withCNAs at three long‐term care facilities. Four themes emerged from the data:CNAwork is good or special;CNAas relationship builder;CNAas expert;CNAas team member. These themes reflect the perceptions that theseCNAs held in regard to themselves and their relationships to others in the work environment and, when present, can contribute to intrinsic job satisfaction. Our meaning‐making themes support the premise thatCNAs do not passively accept the evaluations of others but instead actively frame identities that validate their importance to residents and the institution. (shrink)

Background:Through education, individuals acquire knowledge, skill and attitudes that facilitate professional socialization; it involves intellectual, emotional and psychomotor skill development. Teachers are role models for behaviour modification and value development.Objective:To examine students’ perceptions of faculty members’ ethical and unethical attitudes during interactions in undergraduate nursing.Research design:This descriptive study consisted of two phases. In Phase I, we developed an instrument, which was administered to nursing students to assess validity and reliability. Exploratory factor analysis yielded 32 items. Cronbach’s α was (...) 0.83, and test–retest reliability was good. In Phase II, a 32-item version of the instrument was administered to nursing students from another university.Participants and research context:Participants included 219 nursing students from one university in Phase I and 196 from another university in Phase II. The study was conducted at the universities attended by the participants.Ethical considerations:Ethical approval was granted by the institutions involved, and all participants provided informed consent.Findings:In Phase I, the instrument demonstrated good psychometric properties for measuring nursing students’ perceptions of faculty members’ ethical and unethical behaviours. In Phase II, students considered certain professional and personal qualities, including respecting confidentiality and students’ private lives and assuming an impartial stance during interactions in the classroom, examinations, or clinical practice, ethical. They considered using obscene examples or unprofessional speech during teaching, selling textbooks in class, using university facilities for personal interests, engaging in romantic relationships with students, and humiliating students in front of patients or staff in clinical settings unethical.Conclusion:Results of this study suggest that nurse educators should be aware of their critical role in the teaching–learning process, and they must scrutinize their attitudes towards students from an ethical point of view. (shrink)

BackgroundA special characteristic of nursing education is that professional teaching takes place in various locations. The learning locations involved (such as learning in theory, learning in clinical practice, or learning in third facilities, which are becoming increasingly popular, such as the skills lab) have an impact on and promote the development of ethical competences among prospective nursing professionals in various ways. Furthermore, it has become evident that the structural conditions that are specific to teaching and learning in (...) nursing education programs shape the organization of ethics education and the promotion of ethical competence development among nurse trainees over the course of their education.ObjectivesThe aim of this article is to discuss the following key question: What are the specific pedagogical and didactical requirements and educational frameworks that arise in view of the various learning locations in nursing education in order to facilitate ethics education and ethical competence development among prospective nursing professionals?DiscussionThis article emphasises the importance of a systematic, methodically reflected and learning-location-coordinated approach to ethics education in the field of nursing education. Moreover, it highlights the relevance of the conscious promotion of settings for ethical reflection within the process of ethical competence development in the different locations of learning. The unique quality of ethics education in nursing emerges from the professional requirements that are characteristic to nursing care and the individual experiences of trainees at the various locations of learning throughout their nursing education program. (shrink)

One of the unspoken issues in public discourse in most countries is the racism of patients toward nurses who originate from a different ethnic group than theirs. The aim of the present study is to examine whether patients' racism toward nurses increases as the invasiveness of treatment rises. This study was conducted in Israel, a highly conflictual society where Jews and Arabs live together and meet in the same health facilities. Despite the tension and sometimes animosity caused by the (...) political situation, members of each group regularly encounter members of the other group during the provision of health‐care, both as patients and as medical and nursing staff. A study questionnaire which presented nine nursing treatments of diverse levels of invasiveness was filled out by Arab and Jewish participants. They were asked to convey their preference for an Arab or a Jewish nurse for each treatment. Results of Logistic Regression Analyses reveal that in both sectors, racism toward nurses increases as the treatment invasiveness rises. These findings are discussed in light of the concept of social distance, and serve as an empirical basis for several proposed practical recommendations for eradicating racism against nurses. (shrink)

Background:Protecting the dignity of elderly residents of facilities and providing dignified care can be difficult. Although attempts have been made from several aspects, dignity is considered an area in which less real impact has been made in both theory and practice.Objective:The objective of this study is to characterize the concept of dignity in care for elderly subjects in residential facilities from a practical perspective through concept synthesis.Research design:This study includes in-depth interviews with residents of elderly facilities and (...) a literature review.Participants and research context:A total of 12 residents of seven facilities in three prefectures in Japan were recruited via purposive sampling, and 27 interviews were conducted. Each digitally recorded interview was transcribed verbatim. The interview data were analyzed based on hermeneutic phenomenological research. The literature was searched using PubMed, CINAHL, and Web of Science with combinations of terms such as dignity, elderly, and residential facilities and then selected according to the predefined inclusion criteria. The descriptions about dignity in the included studies were divided into codes and compared with the results of the interviews.Ethical considerations:This study was approved by the institutional review board of Nagoya University’s Graduate School of Medicine.Findings and discussion:There were 1728 data codes for the interviews from which four themes were generated. In the literature review, 3716 titles were searched, and 28 articles were selected. Combining these results, five following themes and a conceptual matrix were obtained: individual dignity not affected by others; dignified care in a narrow sense; elements of the staff side; dignity in relation to family members, friends, society, and other residents; and dignity in relation to nursing care facilities and the nursing care system.Conclusion:According to the established matrix, we must consider the role of the care system, facility, family, and society in providing care with dignity and the individual dignity to residents and dignity in daily care. (shrink)

XIAO LD, KELTON M and PATERSON J. Nursing Inquiry 2012; 19: 322–333 Critical action research applied in clinical placement development in aged care facilitiesThe aim of this study was to develop quality clinical placements in residential aged care facilities for undergraduate nursing students undertaking their nursing practicum topics. The proportion of people aged over 65 years is expected to increase steadily from 13% in 2006 to 26% of the total population in Australia in 2051. However, when (...) demand is increasing for a nursing workforce competent in the care of older people, studies have shown that nursing students generally lack interest in working with older people. The lack of exposure of nursing students to quality clinical placements is one of the key factors contributing to this situation. Critical action research built on a partnership between an Australian university and five aged care organisations was utilised. A theoretical framework informed by Habermas’ communicative action theory was utilised to guide the action research. Multiple research activities were used to support collaborative critical reflection and inform actions throughout the action research. Clinical placements in eight residential aged care facilities were developed to support 179 nursing students across three year‐levels to complete their practicum topics. Findings were presented in three categories described as structures developed to govern clinical placement, learning and teaching in residential aged care facilities. (shrink)

Our 2021 article, "Dying Well in Nursing Homes During COVID-19 and Beyond: The Need for a Relational and Familial Ethic," addresses the response to the COVID-19 pandemic within nursing homes and the impact it had on the lives of residents, care providers, and families. We acknowledge that, at the height of the pandemic, when infection and death rates were soaring in these facilities, extreme "lockdown" measures may have been justified; but these measures resulted in significant relational costs. (...) The collateral damage caused by these lockdown measures included extreme isolation, loss of community, and experiences of confusion, depression, and mental decline for the elderly residents that... (shrink)

Background Improving the competencies of nurses requires improving educational methods through the use of novel methods in teaching and learning. We aim to explore the perceptions of stakeholders (including nursing education directors, faculty members and nursing students) of the requirements of implementing innovative educational approaches in nursing. -/- Methods In this qualitative descriptive study, 19 participants, including educational directors, faculty members, and undergraduate and graduate nursing students, were selected through the purposeful sampling method. Achieving the theoretical (...) saturation in extracted categories was considered as a criterion for determining the sample size and the completion of sampling. The data were collected from December 2019 to May 2020 in nursing schools of Tehran, Iran, through in-depth semi-structured individual face-to-face interviews and were then analyzed based on the Graneheim and Lundman method. -/- Results Using qualitative content analysis, eight sub-themes and three themes were extracted. The extracted themes were ‘novel educational policymaking’, ‘Innovative education-oriented platform’, and ‘managing barriers of innovative educational approaches’. -/- Conclusions Developing and implementing innovative educational approaches entail providing appropriate context, structure, and required facilities by the policymaking system and educational authorities. In addition, developing capacity and related competencies of faculty members and students as the major stakeholders in employing these approaches is crucial. (shrink)

Background: Advocacy is an important role of psychiatric nurses because their patients are ethically, socially, and legally vulnerable. This study of Japanese expert psychiatric nurses’ judgments of interventions for patient advocacy will show effective strategies for ethical nursing practice and their relationship with Japanese culture. Objectives: This article explores Japanese psychiatric nurses’ decision to intervene as a patient advocate and examine their ethical, cultural, and social implications. Research design: Using semi-structured interviews verbatim, themes of the problems that required interventions (...) were inductively summarized by a qualitative analysis and their contexts and nursing judgments were examined. Participants and research context: The participants were 21 nurses with 5 or more years of experience in psychiatric nursing. Ethical considerations: The research was approved by Institutional Review Board of research site and study facilities. The participants gave written informed consent. Findings: Analysis of 45 cases showed that nurses decided to intervene when surrounding people’s opinions impeded patients’ safety, healthcare professionals’ policies impeded patients’ decision-making, own violent behaviors impeded treatment and welfare services for patients, own or families’ low acceptance of illness impeded patients’ self-actualization, inappropriate treatment or care impeded patients’ liberty, and their families abused patients’ property. Discussion: To solve conflicts between patients and their surrounding people, the nurses sought reconciliation between them, which is in accordance with Japanese cultural norms respecting harmony. When necessary, however, they protected patients’ rights against cultural norms. Therefore, their judgments cannot be explained by cultural norms alone. Conclusion: The findings indicate that the nurses’ judgments were based on respect for patients’ rights apart from cultural norms, and they first sought solutions fitting the cultural norms before other solutions. This seems to be an ethical, effective strategy if advocates know the culture in depth. (shrink)

Definition of the problemMedical and nursing care often takes place within complex organizational structures that comprise numerous facilities at numerous locations. We introduce an interactive ethical concept, designed in cooperation with the diaconal foundation BruderhausDiakonie Reutlingen and the International Centre for Ethics in Science, University of Tübingen, to address the particular needs of such organizations.ArgumentsTherefore we portray the interactive Nijmegen Model which combines an ethics committee located at the management level and situational ethical case deliberations on the ward (...) in order to bring together two indispensable ways of ethical reflection in organizations: “top-down”/“bottom-up”. We illustrate the challenges of implementing the said model into the organizational construction of the BruderhausDiakonie and how to address these by means of conception and implementation.ConclusionConsidering the implementational challenges that we encountered, the Nijmegen Model needs to be enhanced by introducing a link between the committee and the case deliberations. We delineate the basic elements and the requirements for such a position while reporting our initial practical experience with this model. (shrink)

Background The emerging working conditions triggered by the COVID-19 pandemic have imposed numerous ethical challenges on the nurses, which, in turn, can negatively impact the nurses’ physical and mental health, and thus their work performance through intensifying negative emotions and psychological pressures. Aim The purpose of this study was to highlight the nurses’ perceptions of the ethical challenges that they faced regarding their self-care during the COVID-19 pandemic. Research design A qualitative, descriptive study with a content analysis approach. Participants and (...) research context The data were collected through semi-structured interviews with 19 nurses working in the COVID-19 wards of two university-affiliated hospitals. These nurses were selected using a purposive sampling method and the data were analyzed using a content analysis approach. Ethical considerations The study was approved by the TUMS Research Council Ethics Committee under the code: IR.TUMS.VCR.REC.1399.594. In addition, it is based on the participants’ informed consent and confidentiality. Findings Two themes and five sub-themes were identified, including ethical conflicts (the conflict between self-care and comprehensive patient care, prioritization of life, and inadequate care) and inequalities (intra- and inter-professional inequalities). Conclusion The findings demonstrated that the nurses’ care is a prerequisite for the patients’ care. Considering that the ethical challenges faced by nurses are related to unacceptable working conditions, organizational support, and lack of access to facilities such as personal protective equipment, it seems essential to support nurses and provide adequate working conditions to provide patients with quality care. (shrink)

BackgroundEthical decision-making of nurses could affect patients’ recovery and also decrease medical costs. To make ethical decisions, ICU nurses experience complicated ethical conflicts. Considering the multi-dimensional process of ethical decision-making, the present study was conducted to describe the experiences of ICU nurses regarding ethical decision making.MethodThe present research is a qualitative study with conventional content analysis approach that was done in 2020. Fourteen ICU nurses were interviewed using a semi-structured in-depth interview method. The interviews were recorded, transcribed verbatim, and analyzed (...) using Granheim and Landman approach.ResultsBeing torn by inevitable moral dilemma was defined as the main category which contained the categories of conflict with professional self, feeling squeezed between self-authority and demands of others, and Surrounded by organizational limitations.ConclusionsResults of the present study showed that moral dilemma is a situation in which the nurses are forced to choose between two options based on their equipment and facilities. In these situations, the nurses would hesitate between their internal conflicts and confusion between choosing their own benefits and patients’ benefits. To prevent ethical challenges in decision making, it is necessary to educate healthcare team about ethical dilemmas and empower the personnel for encountering ethical challenges. (shrink)

Based on action research as a practitioner‐involving approach, this article communicates the findings of a two‐year study on implementing patient participation as an empowering learning process for both patients and rehabilitation nurses. At a rehabilitation facility for patients who have sustained spinal cord injuries, eight nurses were engaged throughout the process aiming at improving patient participation. The current practice was explored to understand possibilities and obstacles to patient participation. Observations, interviews and logbooks, creative workshops and reflective meetings led to the (...) development and testing of four new rehabilitation initiatives aimed at enhancing patient participation. This study suggests that skills of critical reflection from action research toolbox shed light on both the notion of patient participation and caring in nursing rehabilitation. By actively involving nurses in research, the knowledge development stems from practice and the solutions therefore became practice‐oriented. In addition, the personal and professional development experienced by the involved nurses points to a secondary gain in the form of an analytical and reflective approach to complex issues in relation to patient participation, rehabilitation in general and the individual nurses' sense of professional pride. (shrink)

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. (shrink)

Twenty-five long-term care nurses in eight nursing homes in central Kentucky were inter viewed concerning ways in which they might assist elderly residents to preserve and enhance their personal autonomy. Data from the interviews were analysed using grounded theory methodology. Seven specific categories of assisting were discovered and described: personalizing, informing, persuading, shaping instrumental circumstances, considering, mentioning opportunities, and assessing causes of an impaired capacity for decision-making. The ethical implications of these categories of assisting for clinical prac tice are (...) examined. Although nurses recognized the importance of resident autonomy, the majority of them failed consistently to employ the categories of assistance to foster resi dent self-determination and most of them held an inadequate understanding of the con cepts of consent and decisional capacity. To assure confidentiality, pseudonyms are used in the following cases and discussions for all names of nurses, residents and facilities. (shrink)

This article contributes to carework scholarship by examining the nexus of gender, class, and race in long-term care facilities. We draw out a family ideology at work that promotes good care of residents and thus benefits nursing homes. We also found that careworkers value fictive kin relationships with residents, yet we uncover how the family model may be used to exploit these low-income careworkers. Reflecting a subordinate and racialized version of being “part of the family,” we call for (...) an ethic of reciprocity and for concrete change toward valuing equally the humanity of those who need and those who give care. (shrink)

Since the 1970s, the designation of some patients as ‘not for resuscitation’ (NFR) has become standard practice in many health care facilities. Considerable disquiet has subsequently arisen about the way these decisions are implemented in practice. Nurses, in particular, often find themselves initiating or withholding cardiopulmonary resuscitation (CPR) in situations characterized by verbal orders, euphemistic documentation and poor communication, and when consultations with patients about their CPR choices often do not take place. These practices have developed in large part (...) because a clear legal foundation for withdrawal of treatment decisions such as NFR is still lacking in many countries. The problems with NFR were identified in the 1970s and 1980s and are not new, but, as yet, we have not been able to bring about the necessary changes, in effect to translate broadly accepted ethical principles into clinical practice. This paper explores some of the reasons for this and provides a review and analysis of the main issues, including NFR guidelines and the nursing role in NFR decision-making. (shrink)

BackgroundAlthough, moral distress presents a serious problem among critical care nurses in many countries, limited research has been conducted on it. A validated scale has been developed to evaluate moral distress and has enabled cross-cultural comparison for seeking its root causes.Research aimsThis study aimed to (1) clarify the current status of moral distress among nurses who worked in critical care areas in Japan, (2) compare the moral distress levels among nurses in Japan with previously reported results from the United States (...) (US), and (3) explore the factors associated with moral distress.Research designA nationwide cross-sectional study was conducted.Participants and research contextWe conducted a self-administered questionnaire survey using the Measure of Moral Distress–Healthcare Professionals (MMD-HP) among critical care nurses who were randomly selected from hospitals across Japan. The mean differences between the two countries were compared using a Student's t-test with summary statistics. The factors associated with higher levels of moral distress were examined using a multiple regression analysis.Ethical considerationsThe study was approved by the Ethics Committee of the Tokyo Medical and Dental University (approval nos. M2018-214 and M2019-045).ResultsWe obtained 955 valid responses from 94 facilities. In Japan, the items with the highest moral distress scores were those related to aggressive/inappropriate treatment. The total MMD-HP score was significantly higher in Japanese nurses compared to US nurses (122.8 ± 70.8 vs 112.3 ± 73.2). Some factors, such as leadership experience, were associated with higher moral distress.DiscussionThe top root causes of moral distress were similar to potentially inappropriate treatments in both countries.ConclusionThis study revealed the factors associated with higher moral distress and its characteristics in each country. These results can be used for reducing moral distress in the future. (shrink)

Background: Caregivers and administrators in long-term facilities have fragile moral work in caring for residents with dementia. Residents are susceptible to barriers and vulnerabilities associated with the most intimate aspects of their lives, including how they express themselves sexually. The conditions for sexual agency are directly affected by caregivers’ perceptions and attitudes, as well as facility policies. Objective: This article aims to clarify how to approach capacity determinations as it relates to sexual activity, propose how to theorize about patient (...) autonomy in this context, and suggest some considerations for finding an ethically responsible and practically feasible way to respect the sexual rights of this population. Research Design: The focus is on residents with early to moderate dementia in states of daily dependency on professional caregivers. The article critically examines existing empirical research on sexuality among persons with dementia, caregivers’ attitudes, and institutional roadblocks to enabling residents’ sexuality. A relational lens and insights from disability studies are used in the philosophical analysis. Participants and Research Context: No research participants were part of this analysis. Ethical Considerations: This article offers a conceptual analysis and normative framework only. Findings: The analysis highlights the delicate balance that capacity assessments for sexual activity have to strike; while caregivers should protect those who cannot give adequate consent, the denial of sexuality among residents can cause deep, long-ranging harms. Sexual agency features into an ongoing sense of self for many individuals with dementia, and the imposition of inappropriate standards and expectations for sexual autonomy can lead to unwarranted obstacles to sexual activity. Discussion: Recommendations include developing clear and inclusive institutional policies and practices of care, providing education for caregivers on how to discuss and document residents’ sexual preferences over time, and taking advantage of ethics consultation services. Conclusion: This analysis establishes the need for more research and discussion on this sensitive topic. Future research should investigate the specific responsibilities of caregivers in furthering the sexual interests of residents, how exactly to modify existing capacity instruments, and how best to support historically marginalized patients in their sexual identities. (shrink)

This paper opens with first‐hand accounts of critical care medical interventions in which detainees, in the custody of U.S. Immigration and Customs Enforcement (ICE), are brought to the emergency department for treatment. This case dramatizes the extent to which the provision of ethical and acceptable nursing care is jeopardized by federal law enforcement paradigms. Drawing on the scholarship of Michel Foucault and Giorgio Agamben, this paper offers a theoretical account of the power dynamics that inform the health care of (...) patients who find themselves caught in the custodial scaffolding of a vast immigration and detention apparatus. It offers an analysis of the display of sovereign and biopolitical power over the lives (and deaths) of detainees (Foucault), as well as the ways these individuals are reduced to “bare life” under the political pretext of an emergency or “state of exception” (Agamben). Our purpose here is both theoretical and practical: to better understand the often hidden agency or impersonal “will” exercised by the immigrant detention system, but also to equip clinicians in these and cognate facilities (e.g., prisons) with the critical tools by which they might better navigate incommensurable paradigms (i.e., care vs. custody) in order to deliver the best care while upholding their ethical duties as a care provider. This is all the more pressing because hospitals are not sanctuaries and given the incursion of federal law enforcement agents, nurses may find themselves conscripted as de facto agents of the state. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Pride in Giving Care and Other Life Lessons from Certified Nursing AssistantsDelese WearMy father spent the last three weeks of his life in a hospice care facility. It's funny, now reading these narratives written by Certified Nursing Assistants (CNAs), that I can't picture him without Gloria, the CNA who worked the 7-3 shift, floating quietly in and out of his room, tending to him, tending to us, (...) speaking quietly to Dad even when he was no longer conscious, offering us conversation, often her affectionate observations of Dad and curiosity about his life, sometimes about life on the "outside," a kind of respite from total attention on Dad and our grieving. I remember the smell of the lotion she rubbed on his body. I remember no other caregivers in his room; there obviously were, but I can't picture them now, only Gloria. We never spoke directly to the medical director of the hospice. He was a phantom, rounding at 5 or 6 a.m.; we came to believe he did so to avoid speaking to families.Those three weeks led to my conceptions about CNAs—the nature of the work they do, the kinds of people who do such work, the awesome responsibilities involved in such work, and not least, the physical and emotional resiliency of those who undertake such work. My and my family's often recited, "How does she do this every day?" was answered time and again in the narratives written by CNAs in this issue of the journal.But before moving forward, I want to make note of how I will refer to the authors of these narratives. The name of one's occupation, the title one uses, and how others refer to your occupation, is obviously meaningful. If the snapshots of CNAs provided in these narratives are somewhat representative, we find those who refer to themselves and their occupation as nursing assistants, nurse assistants, Certified Nursing Assistants (CNAs), State Licensed Nursing Assistants (SLNA), or simply aides, to name a few. While it is beyond the space offered here, I want to make note of this, recognizing that titles/labels matter, and to acknowledge that status. As CNA Nanci Robinson notes, "most of us are certified... I wouldn't call an LPN a PN and leave out she's licensed." Passage of the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), required each State to establish State-approved nurse aide training programs and establish requirements for nurse aide competency. Thus, I will refer to all the authors here as Certified Nursing Assistants (CNAs). I do wonder how significant of an issue these variations of titles are within the larger nursing assistant culture, and how it may contribute to disparities regarding pay schedules, duties, status, training and other relevant issues among all nursing assistants.In spite of problems, stressors, and other quality of life issues for CNAs, most of them spoke with pride and meaning regarding what was for many their "life's work," similar to what one might expect to find in other care giving occupations. Some spoke of a "love of the work," its "rewards" and "joys," [End Page 165] and the intense satisfaction of "making a difference" in patients' or residents' lives. These attitudes were not vague abstractions but were grounded throughout the narratives in rich examples of the affirming aspects of their work.It appears that much of the pleasure comes from what many refer to as the "hands on," "direct care," or "front line" nature of the work—often what other health professionals might view as things they would not want to do. And of course these other professionals—registered nurses, occupational therapists, and physicians—could make the same claim when describing the "hands-on" joys of their work. But the differences, it would seem, are profound between these other caregivers and CNAs. The CNA narratives report fundamentally intimate and often daily relationships with their clients/residents/patients. Danny Reed describes the "delight" he feels "in restoring dignity to every human in need of it regardless of cause," referring to himself as a "participant observer in a caring relationship," not as a "detached clinician." Many spoke directly... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:What Power Do I Have? A Nursing Student’s Concerns Lead to a Passion for EthicsAnonymous OneThe day began like many in our ten–week rotation, around the large table in the brightly lit ICCU nurses’ station. Report, which was given by the night charge nurse, included information on all the patients on the unit. Since I had cared for A. G. the previous day, I was eager to know (...) how she had spent the night. She had a debilitating neuro–muscular disease known as myasthenia gravis. Placed on the ventilator days before, it was reported that she was likely to be dependent on the machine for life. In the late 1970’s there were very few facilities that accepted ventilator dependent patients. She might be with us for a long time.When I entered her room for the first time, I saw a frail older woman with kind eyes and a warm smile. She was breathing with the help of the ventilator through her tracheostomy tube. I learned through her chart that she had no known family. On the day I took care of her, no one came to see her and she had no visitors the previous evening. She lived in a local long–term care facility and was brought to the hospital after she developed respiratory distress. A. G. was unable to move in the bed due to her condition and required frequent suctioning along with turning and repositioning for comfort.Despite her weakness, A. G. was able to communicate silently by mouthing the words for what she wanted and by nodding and shaking her head. I found her to be quite skilled in non–verbal [End Page 93] communication since it took minimal effort to understand what she wanted, but the activity tired her easily. I had just completed A. G.’s morning care when her physician came in to examine her. After completing his assessment, he stopped and leaned in closely to speak with her. He began asking a number of questions about whether she wanted to spend the rest of her life in this way, on a ventilator. She shook her head. Continuing the line of questioning in different ways, she responded to him. I wondered why he was asking these questions. After seeing her response, the physician asked me to get 30 mg of morphine from the narcotics cabinet. Although I didn’t understand the implication of the request, I complied.While I was retrieving the medication from the narcotics cabinet, the charge nurse came to tell me I was being reassigned to a new admission. When I asked why, she told me she couldn’t discuss it, but asked me to please do what she said. I left her standing there, wondering what was going on. After assisting with the new admission, I went back to see A.G.; her door was closed. When I opened the door, the ventilator tubing hung over the side of the machine. Looking down at the bed, I was shocked to find A.G. had been disconnected. She was dead. In a state of disbelief and panic, I sought out the charge nurse to find out what happened. It was clear that I was not to know. I asked her a number of questions but she adeptly changed the subject and redirected me to other activities. By then it was lunchtime and my instructor had left the unit. I asked to be excused and went to seek her out.When I told my instructor what happened, a look of doubt came over her face. “You think Doctor M. killed your patient? That would never happen.” Although I tried to tell her the story, she too, dismissed me, telling me my story didn’t make sense. I was distraught. An overwhelming sense of dread came over me and I began to cry. She encouraged me to go home, which I did.Happily, I had the weekend to recover before returning to clinical. I never found out what happened to A. G. and neither my instructor nor the charge nurse ever spoke to me about my experience. In fact, it seemed no one believed my story... (shrink)

Background Person-centred care is based on ethical principles, and it is regarded as high-quality care. Care of older persons should embrace person-centredness. During the pandemic, older persons were highlighted as a vulnerable group at risk of developing serious illness and/or suffering death from COVID-19. Several pandemic-related measures were introduced in residential care facilities (RCFs) to reduce this risk, which influenced the possibilities to lead and provide a person-centred care. Aim This study’s aim was to explore ethical challenges in relation (...) to person-centredness during the COVID-19 pandemic, from the perspective of leaders in RCFs. Research design The study had a qualitative descriptive design. Participants and research context Semi-structured interviews were conducted with 26 leaders working in RCFs in Sweden. Data were analysed using conventional content analysis. Ethical considerations The study was approved by the Swedish Ethical Review Authority. The participants received oral and written information about the study and gave written consent. The study was conducted in accordance with the Declaration of Helsinki. Findings The overarching ethical challenge was Having to disregard the individual needs of the person in order to protect the group and society. This included (a) Protecting the group versus promoting the older person’s autonomy; (b) Being forced to lead care based on uncertainty instead of evidence; (c) Striving to provide dignified care but lacking opportunities; and (d) Going far beyond ordinary duty and endangering one’s own and the staff’s health. Discussion The ethical challenges meant being torn between the person’s individual needs and protecting the group and society, with clashing ethical principles as a consequence. Conclusions The leaders faced ethical situations resulting in undignified and compromised person-centred care, which has implications for stakeholders and management who need to address the work conditions in RCFs. (shrink)

Background Interest in strengthening residents’ autonomy in nursing homes is intensifying and professional caregivers’ experience ethical dilemmas when the principles of beneficence and autonomy conflict. This increased focus requires expanded knowledge of how residents experience decision-making in nursing homes and how being subject to paternalism affects residents’ dignity. Research question/aim This study explored how residents experience paternalism in nursing homes. Research design This study involved a qualitative interpretive design with participant observations and semi-structured interviews. The interpretations were (...) informed by Gadamer’s hermeneutics. Participants and research context Eleven residents were interviewed after a period of participant observation in two nursing homes. Ethical considerations The study was performed in accordance with the Helsinki declaration. The Regional Ethics Committee (REK) permitted the researcher to perform participant observation in the nursing homes. The use of audio recordings of interviews was registered and supervised by Sikt - Norwegian Agency for Shared Services in Education and Research. The resident’s consent was assessed continuously. Three interviews were terminated for ethical reasons. Findings The resident interviews revealed that residents found it obvious for caregivers to possess the decision-making authority in nursing homes. When residents explained their views, three main themes emerged: (1) To be included even though caregivers make the decisions, (2) Surrender to dependency, and (3) Adherence to nursing home norms. Conclusions Residents submit to their caregivers and give caregivers the responsibility and function as leaders. Paternalism was experienced as dignifying in situations where it contributed to residents being able to live according to second order desires and values, and when it implied respect and appraisal of residents’ capabilities. Paternalism was experienced as debasing when residents felt left out, and when residents felt that their capabilities were underestimated. This also included their capability to withstand paternalistic influence. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Training and Other Important Needs for Nursing AssistantsNanci RobinsonTraining of Nursing AssistantsI think the nursing assistant (NA) training programs should be longer. My original course for Long Term Care was four weeks long after that I took an additional two months at a hospital to work on a Med/ Surg floor. So, I have a combined three months of schooling.Personally, I'd like to see certified (...) class='Hi'>nursing assistants (CNAs) given more responsibilities. I'd like to see a six-month program to include CPR and capillary blood glucose (CBG) training as well as more in depth anatomy training. I think six months would keep some, who are just looking for money, out of the field and help keep those of us who really want a career in nursing in the field. It would be a better stepping stone for those who plan to go on to a LPN or RN program.I currently have CBG training but my employer will not let me use it. It's disappointing because it's a skill I have that I can't use and it could really help out the nurses. I think if courses were a bit longer, CNAs might be taken a bit more seriously by their employers and respected by their colleagues in the medical field.I was trained in CBG while working for the hospital and received a card like a CPR card to show I was trained. I live and work and was trained in Arkansas. I'm not allowed to do CBGs in the long-term care and rehab facility where I work now, though. However, unless the resident is diabetic we do have to clip and file nails. It took many years for nurses to gain respect and be allowed to do some things that now CNAs do. For example, for many years doctors didn't feel nurses were qualified to even take vital signs. I suppose CNAs will have the same struggle. [End Page 147]"I'm wondering if extending the initial training time would not keep many out of the field, because they need a job with income ASAP." The same could be said for LPN training, could it not? Or even an RN. I don't understand why there is a train of thought that "anyone" should be allowed to be a CNA and as quickly as possible. I can tell when I'm working alongside a Certified Nursing Assistant who is in it because they want to be versus someone who wants the paycheck (not sure why, though, because to be honest Arkansas doesn't pay CNAs all that great, though I suppose for some it might be better than McDonalds). I took a $5 an hour paycut go get back into nursing because it's my passion, and while we all need a paycheck, that should not be the only reason for doing this work."If extending the initial training time would keep many out of the field because they need a job with income ASAP, maybe employer facility-specific follow-up training would seem to be much more feasible for all. A CNA-in-training could be responsible for a lighter than 'normal' shift assignment while under the guidance of a qualified proctor CNA. It could improve efficiency and quality of care in the long run and probably improve retention rate of CNAs, for those administrators that are astute enough to consider the long-term effects of their policies." This might be good—the only problem is that most facilities aren't going to want to absorb any cost this might create by having additional staff for this purpose. Also, on the job training is not appreciated by employers as much as what might be considered actual "education" hours. Most CNAs want to do as much patient care as they can for the nurse—learning to assist with dressing changes, CBGs and other things that would be beneficial for both CNAs and the Nurse.Ensuring there is enough staff and that those staff members are there for the right reasons would do much more to improve the retention rate of NAs or CNAs. (I'm a... (shrink)

The high-tech health service work done by amateur family caregivers in U.S. homes challenges the conventional division of the social world into public and private. Under new federal reimbursement systems, the diagnosis-related groups, patients are being discharged sicker than before from hospitals and nursing homes, or after treatments in outpatient clinics. Health care facilities depend on a work transfer, shifting their earlier responsibilities for the sick to the family. There, women family members do for free the work once (...) done by paid health service workers in health care facilities, caring for family members who need their nursing and housekeeping services. Women's unpaid work knits together “public” and “private,” demonstrating how capitalism reorganizes the labor process to make use of free service labor. (shrink)

For those with advanced life-limiting illness, the optimization of quality of life and avoidance of nonbeneficial treatments at the end of life are key ethical concerns. This article evaluates the efficacy of an Interdisciplinary Ethics Panel (IEP) approach to decision making at the end of life for unbefriended nursing home residents who lack decisional capacity and have advanced life-limiting illness, through the use of a ninestep algorithm developed for this purpose. We reviewed the outcomes of three quality-of-care phased initiatives (...) conducted in our facility, a large public nursing home in New York City, between June 2016 and February 2020, which indicated that this IEP approach promoted advance-care planning, as palliative measures were endorsed to optimize quality of life for this vulnerable population at the end of life. We also examined another quality-of-care initiative when this IEP approach was applied to end-of-life decision making for nursing home residents who had a surrogate during the COVID-19 pandemic. This application appeared to be beneficial in adding more residents to our Palliative Care Program while it improved rates of advance-care planning. When all of the above findings are considered, we believe this novel IEP approach and algorithm have the potential to be applied elsewhere after appropriate assessment. (shrink)

Definition of the problem This interview study investigated ethical issues in long-term care facilities from the perspective of caregivers during the coronavirus disease pandemic. Due to the explorative as well as descriptive methodological approach, interview data are available and can be assigned to four central topics, which reveal a complex and sometimes conflictual reality of work and life in long-term care during the pandemic. On the one hand, the protective measures taken by the state and the institutions, as well (...) as the resulting restrictions on the personal freedom of the residents are critically reflected and the degree of self-determination of the residents of nursing homes in the pandemic is questioned. On the other hand – given the pandemic-related measures – nursing activities in long-term care facilities as a place of work and life are described as challenging, especially regarding the changed nursing processes and quality of care, as well as due to the changed quality of relationships with the residents. Arguments These four topics can basically be assigned to the ethical principles of autonomy and care and present a relevant concretization of the principle-oriented ethical challenges in long-term care during the COVID-19 pandemic. In the synopsis and interpretation of the results, it becomes apparent that the interviewed caregivers closely link the observance and implementation of the autonomy principle in everyday nursing care with the principle of care and the resulting well-being of the residents. Conclusions Our results clearly show that the paradigm shift in long-term care, which has been developed over the last few decades, was weakened by the COVID-19 pandemic. In addition, the reported moral uncertainties and conflicts make it clear that caregivers need support regarding the ethical reflection of their nursing actions and that a sustainable integration of ethics counselling in long-term care facilities may be a possible approach to a solution. (shrink)

In United States ex rel. Quirk v. Madonna Towers, Inc., the U.S. Court of Appeals for the Eighth Circuit held that the failure of a skilled nursing facility's executives to seek a legal opinion regarding a billing practice they considered valid did not meet the definition of knowingly presenting a false claim for payment to the federal government under the False Claims Act. Alleging that the facility that provided care to his aunt fraudulently submitted claims to Medicare for services (...) provided free of charge, the appellant brought this case qui tam on behalf of the federal government under the FCA.The FCA was passed by the legislature in an effort to punish and deter fraud against the federal government. It provides financial incentives for private individuals to come forward with information about fraudulent activity. (shrink)

The ethical obligation to provide a reasonably safe discharge option from the inpatient setting is often confounded by the context of homelessness. Living without the security of stable housing is a known determinant of poor health, often complicating the safety of discharge and causing unnecessary readmission. But clinicians do not have significant control over unjust distributions of resources or inadequate societal investment in social services. While physicians may stretch inpatient stays beyond acute care need in the interest of their patients (...) who are experiencing homelessness, they must also consider the implications of using an inpatient hospital bed for someone without the attendant level of medical need. Caring for patients in an inpatient setting when they no longer require acute care means fewer beds for acute care patients. And when a patient who is experiencing homelessness declines a medically safer option such as a skilled nursing facility, then clinicians may be faced with the sole option of discharge to the street, which raises troubling questions of nonmaleficence and social justice. Here we investigate the different forms of injustice that play out when patients are discharged to the street, and offer a map of the interwoven ethical responsibilities of clinicians, hospitals, and skilled nursing facilities. (shrink)

Hospital-dependent patients are individuals who are repeatedly readmitted to the hospital because their acute medical needs cannot be met elsewhere. Unlike the chronically critically ill, these patients do not have a continuous need for life-sustaining equipment and can experience periods of relative stability where they have a good quality of life. However, some end up spending months or even years in the hospital receiving resource-intensive care because they are unable to be safely discharged, despite an initial optimistic prognosis. It is (...) hard to reliably identify these patients on admission and more research is needed to better understand the unique medical needs of this population. But the inability to safely discharge these patients to their home or to a skilled nursing facility without rapid readmissions also creates ethical implications for the physicians who care for them. The aim of this paper is to clarify some of the ethical considerations involved in caring for hospital-dependent patients. Among physicians, the care of hospital-dependent patients is likely to disproportionately affect hospitalists and intensivists, whose care is often evaluated in terms of reducing patient length of stay and readmissions. Because hospital-dependent patients’ medical needs thwart the traditional goal of safe discharge, both clinical ethics and physicians’ professional obligations are implicated by their care. The inability to reliably identify these patients early can complicate discussions about treatment goals and informed consent. Similarly, the tremendous dedication of limited resources to these patients without safe discharge back to the community may raise concerns about the just allocation of healthcare resources. Our current acute care hospitals are not designed to provide long-term care for hospital-dependent patients. Unfortunately, safe discharge options remain elusive for these patients. Further research and support of this population is needed to more reliably identify hospital-dependent patients on admission, better inform the discussions of short- and long-term treatment goals, and more wisely allocate resources both within our acute care hospitals and larger healthcare system. (shrink)