Nurses' perceptions of powerlessness in influencing ethical decisions

The value of nurse bioethicists

BACKGROUND

The field of nursing has long been concerned with ethical issues. The history of the nursing profession has a rich legacy of attention to social justice and to societal questions regarding issues of fairness, access, equity, and equality. Some nurses have found that their clinical experiences spur an interest in ethical patient care, and many are now nurse bioethicists, having pursued additional training in bioethics and related fields (e.g., psychology, sociology).

PURPOSE

The authors describe how the clinical and research experiences of nurses give them a unique voice in the field of bioethics.

RESULTS

Authors present reasons for the relative invisibility of nurse bioethicists, compared with physician, theologian, or philosopher bioethicists, as well as current efforts to increase the visibility of nurse bioethicists. They also describe four specific areas where nurse bioethicists have made and continue to make important contributions: as ethics consultants to colleagues in hospitals and other settings; as bioethics researchers or as advisers to researchers conducting trials with human subjects; as educators of trainees, patients and families, healthcare providers, and the public; and in helping to draft humane and ethical policies for the care of vulnerable patients and underserved populations.

CONCLUSION

Nurse bioethicists are central to the future goals of healthcare bringing a unique perspective to the day-to-day ethical challenges of both clinical care and research, as well as to the education of health professionals and the public.

Negotiated ethical responsibility: Bruneian nurses' ethical concerns in nursing practice

BACKGROUND

There has been wide interest shown in the manner in which ethical dimensions in nursing practice are approached and addressed. As a result, a number of ethical decision-making models have been developed to tackle these problems. However, this study argued that the ethical dimensions of nursing practice are still not clearly understood and responded to in Brunei.

RESEARCH AIM

To explore how Bruneian nurses define ethical concerns they meet in everyday practice in the medical surgical wards of three Brunei hospitals.

RESEARCH DESIGN

A qualitative study was employed. Interviews were conducted with 28 practising and administrative nurses of three hospitals. Interview data were analysed via a constant comparative method.

ETHICAL CONSIDERATION

The study's protocol was reviewed and approved by the Ethical Committee of the School of Health in Social Science at the University of Edinburgh and the Medical Health Research Ethics Committee of the Ministry of Health, Brunei.

FINDINGS

The nurses described three ethical dimensions in their practice, namely: 'nurse at work' which illustrates the ethical dimensions within the work environment; 'nurse and doctor' which elucidates the ethical dimensions in the nurse and doctor relationship; and 'nurse and patient' which further examines ethical aspects in patient care. Nurses responded to the ethical dimensions in the ward setting with the aim of avoiding the conflict and maintaining ward harmony.

DISCUSSION

The data provide new insights into how nurses respond to ethical dimension in the ward settings where it puts strong emphasis on the nurses' understanding of responsibility placed upon them as professional nurses.

CONCLUSION

With these findings, it is recommended that further support is needed for nurses to be aware of the ethical dimension in their practice and to respond to ethical concerns accordingly.

Ethical Problems Experienced by School Nurses

This study explored school nurses’ experience of ethical conflict in school nursing through interviews with six school nurses. The study examined how school nurses resolved ethical problems and the rationale used to resolve them. Emergent themes of ethical problems were professional relationship conflicts, delegation to and supervision of health assistants, child protection reporting, maintaining confidentiality, Do Not Resuscitate policy, and pressure to work outside of nursing practice standards. School nurses did not use ethical decision-making models in resolving conflict but demonstrated the use of professional standards, ethical principles, and personal values as rationale to resolve ethical problems. Results of this study suggested that school nurses would benefit from additional knowledge about ethical decision-making models. School nurses would also profit from hearing each other’s voices through dialogue about ethical problems and decision making.

Nursing Students’ Experience of Ethical Problems and Use of Ethical Decision-Making Models

Using a conceptual framework and method combining ethical enquiry and phenomenology, we asked 73 senior baccalaureate nursing students to answer two questions: (1) What is nursing students’ experience of an ethical problem involving nursing practice? and (2) What is nursing students’ experience of using an ethical decision-making model? Each student described one ethical problem, from which emerged five content categories, the largest being that involving health professionals (44%). The basic nature of the ethical problems consisted of the nursing students’ experience of conflict, resolution and rationale; 85% of the students stated that using an ethical decision-making model was helpful. Although additional research is needed, these findings have important implications for nursing ethics education and practice.

Empirical research on moral distress: issues, challenges, and opportunities

Studying a concept as complex as moral distress is an ongoing challenge for those engaged in empirical ethics research. Qualitative studies of nurses have illuminated the experience of moral distress and widened the contours of the concept, particularly in the area of root causes. This work has led to the current understanding that moral distress can arise from clinical situations, factors internal to the individual professional, and factors present in unit cultures, the institution, and the larger health care environment. Corley et al. (2001) was the first to publish a quantitative measure of moral distress, and her scale has been adapted for use by others, including studies of other disciplines (Hamric and Blackhall 2007; Schwenzer and Wang 2006). Other scholars have proposed variations on Jameton's core definition (Sporrong et al. 2006, 2007), developing measures for related concepts such as moral sensitivity (Lutzen et al. 2006), ethics stress (Raines 2000), and stress of conscience (Glasberg et al. 2006). The lack of consistency and consensus on the definition of moral distress considerably complicates efforts to study it. Increased attention by researchers in disciplines other than nursing has taken different forms, some problematic. Cultural differences in the role of the nurse and understanding of actions that represent threats to moral integrity also challenge efforts to build a cohesive research-based understanding of the concept. In this paper, research efforts to date are reviewed. The importance of capturing root causes of moral distress in instruments, particularly those at unit and system levels, to allow for interventions to be appropriately targeted is highlighted. In addition, the issue of studying moral distress and interaction over time with moral residue is discussed. Promising recent work is described along with the potential these approaches open for research that can lead to interventions to decrease moral distress. Finally, opportunities for future research and study are identified, and recommendations for moving the research agenda forward are offered.

Implicações do sofrimento moral para os(as) enfermeiros(as) e aproximações com o Burnout

Realizou-se uma revisão integrativa, com o objetivo de identificar as implicações do sofrimento moral para os(as) enfermeiros(as), aproximações entre sofrimento moral e burnout, e estratégias de enfrentamento do sofrimento moral, na literatura científica nacional e internacional publicada nos últimos 10 anos. As bases de dados foram CINAHL, MEDLINE e SAGE, e as palavras-chave, sofrimento moral, burnout e enfermagem. Obtiveram-se 21 artigos para análise, realizada em quatro etapas: redução, visualização e comparação dos dados, e verificação e esboço da conclusão. Identificou-se que o sofrimento moral vivenciado pelos(as) enfermeiros(as) manifesta-se na dimensão pessoal, com alterações emocionais e físicas, e na dimensão profissional, com insatisfação no trabalho, burnout e abandono da profissão. Constataram-se estratégias de enfrentamento em três dimensões: educativa, comunicativa e organizacional. Considera-se necessário maior exploração dessa temática, contribuindo para a prevenção do sofrimento moral.

Sofrimento moral e a dimensão ética no trabalho da enfermagem

Trabalhadores de enfermagem vivenciam problemas morais, dilemas morais e sofrimento moral, no seu cotidiano profissional. O sofrimento moral manifesta-se quando os trabalhadores apresentam dificuldades para executar situações moralmente adequadas, segundo suas consciências. O texto tem como objetivo enfocar o sofrimento moral dos trabalhadores de enfermagem e sua relação com problemas morais e dilemas morais, abordando conceitos, vivências de sofrimento moral e possíveis estratégias a serem adotadas para o seu enfrentamento. Enfocar o sofrimento moral provocado pelo enfrentamento de problemas e dilemas morais no trabalho da enfermagem parece fundamental, não apenas para desvelar um fenômeno ainda pouco conhecido, mesmo que vivenciado quase que diariamente, mas, também, para destacar a necessidade de problematização e valorização da dimensão ética do trabalho em saúde.

Nurses' knowledge, attitudes/beliefs, and care practices concerning do not resuscitate status for hospitalized neonates

OBJECTIVE

To describe the knowledge, attitudes/beliefs, and care practices of neonatal intensive care unit nurses concerning do not resuscitate status for hospitalized neonates and to assess differences based on years of neonatal intensive care unit experience and educational background.

DESIGN

Comparative descriptive design.

SETTING

Level 3 neonatal intensive care unit located in the northeastern United States.

PARTICIPANTS

A convenience sample of 66 neonatal intensive care unit nurses.

METHODS

Nurses responded anonymously to an adapted pen and paper questionnaire assessing knowledge, attitudes/beliefs, and care practices regarding the care of hospitalized neonates with do not resuscitate status.

RESULTS

There was much ambiguity concerning the legal meaning of the term "do not resuscitate." Three fourths of respondents did not recognize do not resuscitate by its legal definition. A variety of attitudes/beliefs and care practices related to do not resuscitate designation was reported. Nurses with increased years of experience were less supportive of initiating certain aggressive care modalities for do not resuscitate patients. Responses regarding knowledge, attitudes/beliefs, and care practices related to do not resuscitate designation for neonates did not appear to be influenced by the educational background of neonatal intensive care unit nurses.

CONCLUSION

Neonatal intensive care unit nurses need further education regarding the legal definition and scope of do not resuscitate orders in the clinical care of terminally ill neonates.

Nursing ethics and its relation with power and work organization

Difficulties faced in the nursing routine, mainly in hospitals, have been reported without the resulting ethical implications to workers and especially to clients, been sufficiently questioned. The work organization can be the main source of suffering to nursing workers, related to the exercise of power of different actors involved in the health institutions, which can potentially cause multiple problems and distress of ethical order. This study aims to make a critical reflection about some relations between the nursing work organization, power relations and its ethical dimension. Strategies for an ethical performance of nurses and other nursing professionals in the organization of work in the healthcare institutions point to the need of these professionals exercise power in an ethical way.

Being an intensive care nurse related to questions of withholding or withdrawing curative treatment

AIMS AND OBJECTIVES

The aim of the study was to acquire a deeper understanding of what it is to be an intensive care nurse in situations related to questions of withholding or withdrawing curative treatment.

BACKGROUND

Nurses in intensive care units regularly face critically ill patients. Some patients do not benefit from the treatment and die after days or months of apparent pain and suffering. A general trend is that withdrawal of treatment in intensive care units is increasing. Physicians are responsible for decisions concerning medical treatment, but as nurses must carry out physicians' decisions, they are involved in the consequences.

DESIGN AND METHODS

The research design was qualitative, based on interpretative phenomenology. The study was carried out at an adult intensive care unit in Norway. Data were collected by group interviews inspired by focus group methodology. Fourteen female intensive care nurses participated, divided into two groups. Colaizzi's model was used in the process of analysis.

RESULTS

The analysis revealed four main themes which captured the nurses' experiences: loneliness in responsibility, alternation between optimism and pessimism, uncertainty--a constant shadow and professional pride despite little formal influence. The essence of being an intensive care nurse in the care of patients when questions were raised concerning curative treatment or not, was understood as 'being a critical interpreter and a dedicated helper.'

CONCLUSIONS

The findings underpin the important role of intensive care nurses in providing care and treatment to patients related to questions of withholding or withdrawing curative treatment.

RELEVANCE TO CLINICAL PRACTICE

The findings also show the need for physicians, managers and intensive care nurses themselves to recognize the burdens intensive care nurses carry and to appreciate their knowledge as an important contribution in decision making.

Agents of care and agents of the state: bio-power and nursing practice

AIM

This paper presents a conceptual analysis of the concept of bio-power in the context of nursing, including a critique of the widespread rhetoric that nursing is deprived of power and consequently is an apolitical agency.

BACKGROUND

Traditionally, power tends to be defined in terms of repression, interdiction and punishment. On the contrary, work by Michel Foucault with regard to bio-power brings into evidence the productive and positive nature of power at the heart of society. Despite being often used by various academic and professional disciplines, the concept of bio-power is rarely cited in nursing.

FINDINGS

Nursing as a profession is at the heart of bio-power in that nurses lie at the crossroads between the anatomo-political and bio-political ranges of power over life. They therefore contribute to social regulation through a vast array of diverse political technologies. Nurses are at the flexing point of the state's requirements and of individual and collective aspirations. They occupy a strategic position that allows them to act as instruments of governmentality. Consequently, nurses constitute a fully-fledged political entity making use of disciplinary technologies and responding to state ideologies.

CONCLUSION

The concept of bio-power offers a rich theoretical perspective for nursing, as it questions the definition of nursing care as neutral and mainly provided according to patients' best interests.

Nursing ethics education: are we really delivering the good(s)?

The vast majority of research in nursing ethics over the last decade indicates that nurses may not be fully prepared to 'deliver the good(s)' for their patients, or to contribute appropriately in the wider current health care climate. When suitable research projects were evaluated for this article, one key question emerged: if nurses are educationally better prepared than ever before to exercise their ethical decision-making skills, why does research still indicate that the expected practice-based improvements remain elusive? Hence, a number of ideas gleaned from recent research about the current nature of nursing ethics, and especially teaching nursing ethics to student nurses, are analysed and critiqued in this article, which concludes with a cluster of ideas and conclusions based on that analysis. It is hoped that such a review may serve as a catalyst for nurse educators to re-examine their teaching practices with a view to enhancing good (i.e. ethical) nursing practice through educational means.

Moral conflict and collaborative mode as moral conflict resolution in health care

Moral conflict as a complex moral issue in health care has emerged from several causes that are related to different values, beliefs and opinions. Moral conflict can occur when duties and obligations of health care providers or general guiding ethical principles are unclear. Health care providers and institutions or agencies need to resolve or initiate appropriate methods for professional staff so they can recognize, discuss and resolve moral conflicts in the health care delivery system. Collaborative mode is a useful method for moral conflict resolution, because patient care is a complex phenomenon that results from the integrated knowledge and work of individuals with different professional training. In the process of collaborative practice, all members need to respect each other's opinions, values and responsibilities regarding patient care.

Nursing resistance as ethical action: literature review

BACKGROUND

Much has been written about nursing as a predominantly female profession whose members display passivity, submission, obedience and powerlessness. Alternatively, some authors have presented evidence of nurses' capacity to exercise power, revealing the possible relationship between powerlessness and ethical compromise. Thus, empowerment strategies for nurses can yield ethical action.

AIM

The aim of this paper is to use analysis of the literature to demonstrate how the actions and responses of nurses to ethical concerns are examples of nurses exercising power.

METHOD

Empirical studies published in the nursing literature between 1990 and 2003 have been analysed to illustrate how nurses' actions of resistance can ensure that moral values are realized in practice. Foucauldian notions of power relations and feminist ethics provide the theoretical framework.

CONCLUSIONS

Nurses were found to resist in situations where they experienced moral conflicts in relation to the actions of health professionals; however, instances were cited where they did not. Consequently, strategies for nursing education and management are proposed to increase nurses' understanding of the potential acts of resistance that they could employ in situations of moral conflict or concern.

How delivery ward staff exercise power over women in communication

BACKGROUND

Power is a central element in all social interactions. In order to act appropriately in different care situations, it is important to understand the meaning of power.

AIM

This paper reports a study whose aim was to describe delivery ward staff opinions about the exercise of power over women in communications.

METHODS

Data were collected in 2000 using a questionnaire developed for the study with a convenience sample of 155 midwifery and nursing professionals in delivery wards in four Finnish hospitals.

RESULTS

The results showed that in respondents' opinions they worked for women's good and aimed at relationships based on a sense of equality and individuality. Negative power was used in situations where women's well-being was threatened. The power used was verbal or non-verbal.

CONCLUSIONS

The exercise of power is not only negative in nature. There are times, such as in life-threatening situations, when it is crucial that the professional takes control and makes decisions immediately, and in that sense exercises power.

Principled Thinking: A Comparison of Nursing Students and Experienced Nurses

BACKGROUND

A descriptive study was used to compare ethical reasoning abilities in senior baccalaureate nursing students and experienced registered nurses. The effects of environmental factors and previous experience with ethical dilemmas in regard to nursing principled thinking were also examined.

RESULTS

Findings on the Nursing Dilemma Test indicated a significant difference in the level of nursing principled thinking in the two groups, with nursing students scoring higher than experienced nurses. There was a significant negative correlation between years of experience and level of nursing principled thinking. The level of nursing education (e.g., associate degree of nursing, diploma, bachelor of science in nursing, masters degree, or doctorate) did not appear to have an effect on nursing principled thinking. In addition, subjects who were most affected by practical considerations demonstrated less use of higher level moral reasoning. The effect of previous experience with ethical dilemmas on nursing principled thinking was found to be nonsignificant.

CONCLUSION

Ethical dilemmas continue to create much confusion and uncertainty for practicing nurses. Suggestions are made regarding individual analysis of personal and professional values in nurses. In addition, recommendations include ongoing educational offerings and nursing administration support to assist nurses during times of moral distress.

Health care relationships in context: an analysis of three ethnographies

A qualitative meta-analysis of three ethnographic studies conducted by the original investigators of those studies yielded new understandings of the dynamics of health care relationships in context. Through this analysis, the authors show that moral judgments and decision making in health care are highly relational and contextual. The use of power to compel health care providers and patients to comply with organizational practices is shown as fundamental to organizational functioning, and nurses participate in activities that often perpetuate conditions that contribute to their own moral distress. Furthermore, resistant actions often operate to sustain the practice patterns and ideologies being resisted. The authors call for an understanding of moral distress as relational and for collective strategies to counter practices that thwart ethical practice.

Development of a model of moral distress in military nursing

The purpose of this article is to describe the development of a model of moral distress in military nursing. The model evolved through an analysis of the moral distress and military nursing literature, and the analysis of interview data obtained from US Army Nurse Corps officers (n = 13). Stories of moral distress (n = 10) given by the interview participants identified the process of the moral distress experience among military nurses and the dimensions of the military nursing moral distress phenomenon. Models of both the process of military nursing moral distress and the phenomenon itself are proposed. Recommendations are made for the use of the military nursing moral distress models in future research studies and in interventions to ameliorate the experience of moral distress in crisis military deployments.

The beliefs of nurses who were involved in a whistleblowing event

BACKGROUND

Nursing codes of ethics bind nurses to the role of patient advocate and compel them to take action when the rights or safety of a patient are jeopardized. Reporting misconduct is known as whistleblowing and studies indicate that there are personal and professional risks involved in blowing the whistle.

AIM

The aim of this study was to explore the beliefs of nurses who wrestled with this ethical dilemma.

DESIGN

A descriptive survey design was used to examine the beliefs of nurses in Western Australia who reported misconduct (whistleblowers) and of those who did not report misconduct (nonwhistleblowers).

METHODS

The instrument listed statements from current ethical codes, statements from traditional views on nursing and statements of beliefs related to the participant's whistleblowing experience. Respondents were asked to rate each item on a five-point Likert format which ranged from strongly agree to strongly disagree. Data were analysed using a Pearson's correlation matrix and one-way ANOVA. To further explore the data, a factor analysis was run with varimax rotation.

RESULTS

Results indicated that whistleblowers supported the beliefs inherent in patient advocacy, while nonwhistleblowers retained a belief in the traditional role of nursing. Participants who reported misconduct (whistleblowers) supported the belief that nurses were primarily responsible to the patient and should protect a patient from incompetent or unethical people. Participants who did not report misconduct (nonwhistleblowers) supported the belief that nurses are obligated to follow a physician's order at all times and that nurses are equally responsible to the patient, the physician and the employer.

CONCLUSION

These findings indicate that nurses may respond to ethical dilemmas based on different belief systems.

Moral problems experienced by nurses when caring for terminally ill people: a literature review

This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses' perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment.

Are submissive nurses ethical?: reflecting on power anorexia

We believe that the notion of power anorexia, which we define as a lack of desire to exercise power, is central to reflections about nursing ethical concerns. Questioning the assumption that nurses are powerless, we argue that nurses can and do exercise power and that their actions and inactions have consequences not only for themselves, but also for those for whom they care. We propose that a feminist ethics perspective be used both to understand and to overcome nurses' power anorexia. Feminist thinkers remind us not only of oppression's psychological impact, but that stereotypical views about women are socially constructed and, therefore, can be changed. Nurses using this framework should explore the implications of a centralized notion of caring to the way we conceive of power relations in health care. Perhaps deconstructing caring by focusing on how nurses exercise power could help us to re-conceptualize nursing and promote new agendas for health and health care.

Physical and Emotional Effects of Whistle blowing

This research examined the stress-induced health effects of whistleblowing and non-whistleblowing on nurses in Western Australia. A descriptive survey design was used to explore the physical and emotional problems experienced by nurses who did and did not blow the whistle on misconduct in the workplace. A questionnaire based on Lazarus and Folkman's Model of Stress and Coping was developed and posted anonymously to general and mental health nurses. Ninety-five nurses responded to the questionnaire, and 70 were identified as whistleblowers and 25 were identified as non-whistleblowers. Results indicated that 70% of whistleblowers and 64% of non-whistleblowers experienced stress-induced physical problems from being involved in a whistleblowing situation. The most common physical problems experienced by nurses were restless sleep, fatigue, headaches, insomnia, and increased smoking. In addition, 94% of whistleblowers and 92% of non-whistleblowers suffered stress-related emotional problems, the most frequent being anger, anxiety, and disillusionment. Whistleblowers and non-whistleblowers suffered a similar percentage of physical health problems, whereas non-whistleblowers suffered a higher percentage of emotional health problems, especially feelings of guilt, shame, and unworthiness. These findings suggest that whistleblowing situations are stressful and may cause physical and emotional health problems whether one blows the whistle or not.

Intensive care nurses' experiences of caring for dying patients: a phenomenological study

The experience of nurses working in end-of-life care, particularly those caring for cancer patients in the hospice setting, have been well researched. Yet despite the fact that intensive care units (ICUs) are frequently the site of patient death, studies of the nurses working in these units are uncommon. This study was designed to provide qualitative data to explore the experiences of intensive care nurses caring for patients who are dying. Semi-structured interviews were conducted with ten nurses who had experience of caring for dying patients in ICUs in two teaching hospitals in Taiwan. Data were analysed using a phenomenological descriptive approach. Participants' descriptions revealed the following core themes: considering nurses' attitudes to caring for the dying, stressors associated with this care and coping strategies that intensive care nurses adopt. The study concludes that education for ICU nurses must address these issues to facilitate better care of dying patients in the ICU.

Subject positions theory -- its application to understanding collaboration (and confrontation) in critical care

BACKGROUND

Doctors and nurses do not usually take a collaborative approach to the ethical challenges of the critical care environment. This leads to the stresses that produce moral anguish and burnout -- both for nursing and medical staff. A more collegial relationship between nurses and physicians should improve patient care. If we are to promote this collegiality, one way to proceed is to investigate the interactions between health care professionals in order to develop an understanding of the barriers to, and supports for collaboration.

AIM

Subject positions theory offers a method of explaining and elucidating the interactions between nurse and physician in terms of power dynamics, mutual expectations and the discourse available to each individual. This paper aims to demonstrate how subject positions theory can facilitate the interpretation of the interactions between health professionals in terms of the power dynamics influencing those interactions.

DISCUSSION

This paper will use the example of a case study from my own research to demonstrate the application of this theory and its usefulness in the analysis of the interactions between health care professionals.

CONCLUSIONS

Application of this theory is used to demonstrate the author's argument that the current political and cultural structure of the health care system does not support the subject position - nurse advocate.

The interplay of knowledge and decision making between nurses and doctors in critical care

This paper explores the complex interrelationships between knowledge and decision making as nurses and doctors interacted with each other in a critical care unit, which comprised a combined general intensive care and cardiothoracic surgical unit. The critical ethnographic study upon which this paper is based, involved a research group of six nurses who worked in the unit. Nurses differentially valued their knowledge, depending on the situation, experience and level of medical input. They were also involved in decision making based on their differential visibility in the process. Nurses' specialised knowledge of the critical care unit played a major role in influencing how they interacted during decision making.

Ethical dilemmas and the nurse practitioner in the NICU

With the emergence of advanced practice roles for nurses, including the role of the neonatal nurse practitioner (NNP), nurses are increasingly being placed in the position of making difficult decisions, especially in acute or emergency situations. NNPs, therefore, must have a working knowledge of the ethical decision-making process in order to make appropriate decisions at the bedside.

The feelings nurses and patients/families experience when faced with the need to make bioethical decisions

This study investigates the experience of nurses and patients/families who have been personally involved in bioethical decision making and their consequent reflections on their feelings regarding the decision-making process. The method used was phenomenological. The subjects were 15 nurses, 5 patients, and 11 family members. The analysis of data resulted in 10 themes for each group. For the most part, the experience was a negative one that left the participants feeling frustrated and powerless. The themes have been used to create two visual analog scales (one for the patient and one for the patient/family). The tool is already being pilot tested.

Advocacy in perioperative nursing practice

Advocacy describes the act of pleading for, supporting, and active espousal. It implies taking action to achieve a goal on behalf of oneself or another. In nursing, the patient's wishes often serve as the impetus for advocacy. Perioperative nurses function as advocates and accept responsibility to safe-guard the rights of surgical patients. This article describes historical aspects of and conceptual problems in nursing advocacy, and it presents case studies that demonstrate advocacy by the perioperative nurse.

Professional journalling over time: position of the inside nurse-researcher in intensive care

The purpose of this paper is to examine the use of professional journalling in an intensive care unit. In particular, this paper explores the power and contextual relations that shaped nurse-nurse and nurse-doctor decision-making, from the author's perspective as the inside nurse-researcher. A variety of research methods were used for this study, including professional journalling, participant observation, and individual and focus group interviews. The author also worked as a clinical nurse specialist, as the inside nurse-researcher, in the unit under investigation. The results indicated that the power and contextual relations constructing nurse-nurse and nurse-doctor decision-making focused on two major issues. These concerned: drawing on particular forms of knowledge and acquiring differential visibility by the nurse in decision-making. The study demonstrated that professional journalling is an effective research method for helping nurses to question decision-making critically, not for examining the position of an inside nurse-researcher, and for supporting data obtained from other research methods.

Collaboration between nurses and doctors in clinical practice

Several authors have identified collaboration between nurses and doctors as problematic. Benner (1984) stressed that teamwork and collaboration between the disciplines was crucial for both patient care and team morale. The purpose of this article is to evaluate critically and discuss the research studies which have been conducted into the dynamics of the nurse/doctor relationship. A number of characteristics are significant in influencing the collaborative process. These include excellent communication skills, respecting the value of colleagues' roles, the ability to share points of view and trust.

Whistle-blowing: effective and ineffective coping responses

How do nurses respond when they identify misconduct in patient care settings? The authors used a descriptive survey (N = 95) to identify effective coping strategies of whistle-blowers (n = 70) and non-whistle-blowers (n = 25). Results identified four effective coping strategies used by whistle-blowers. The authors offer recommendations to nurses who encounter misconduct in their workplace.

Nursing, morality, and emotions: phase I and phase II clinical trials and patients with cancer

This article reflects three nurses' views of the moral dimensions of their work in caring for patients receiving phases I and II of cancer clinical trials in a dedicated cancer clinical trials unit (CCTU). The nurses took part in a semistructured, tape-recorded, group interview in which they talked about any aspect of their work that they felt demonstrated its ethical or moral dimensions. The nurses were not employed as research nurses, but had chosen to specialize in cancer and palliative care in a CCTU environment. Three key themes emerged from the interview: being valued and moral distress; caring in a climate of scientific research; and care, cure, and consequences for moral reasoning. Working in an environment suffused with moral conflicts can be painful and damaging for the professionals involved. It would appear that if nurses are to function effectively, they need to be proactive in promoting an exploration of the role that emotions play in moral decision making and in examining the contribution of emotions to what they care about and why. A commitment to a shared understanding and valuing of divergent ethical reasoning in and across professional cultures of care and research paradigms also appears to be necessary. The terms "ethics" and "morals" are used interchangeably throughout this article.

Moral distress, advocacy and burnout: theorizing the relationships

Burnout is a major contributor to shortages of experienced nurses. The research literature shows a correlation between moral distress and burnout in critical care nurses. This paper reports on part of an interpretive interactionist study concerning nurses' experiences of moral distress which prompted attempts to advocate for vulnerable patients. One critical incident is used as an example of the qualitative findings of the study. In this paper, we theorize about what happened when nurses advocated for their patients by challenging medical treatments which the nurses believed to be both inappropriate and to contributing to patient suffering. When attempts at advocacy were unsuccessful, the nurses experienced intensified moral distress, frustration and anger. Being an unsuccessful advocate resulted in nurses being relocated within the hospital, nurses being scapegoated and/or burning out. The theoretical links which this paper makes between advocacy, moral distress and burnout are supported by empirical data from the study.

The message of SUPPORT: Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment. Change is long overdue

The major findings of the Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatment (SUPPORT), a multimillion dollar, multisite investigation of the process of dying in American hospitals, were extremely disappointing to the medical community. The major conclusion of this intervention study was that increased efforts to improve communication about patients' preferences for end-of-life care to physicians did not have a significant impact on the care that is provided in hospitals. In a commissioned series of papers to examine the conclusions of the study, numerous factors were identified as the possible reasons for the SUPPORT findings. Among the factors was the role of nurses in communicating patients' preferences to physicians. Nurses, however, were not participants in the design and conduct of this study nor were they among those who were respondents to the conclusions of SUPPORT. In this manuscript, an analysis of the report of the SUPPORT study itself and the commentaries commissioned by its funding agency are reported. Numerous issues about the scientific rigor of SUPPORT, the perceived roles of nurses in end-of-life decision making, and the need for interdisciplinary collaboration in health care and health care research are presented in an effort to ensure that nurses' contributions to the quality of patient care are recognized, acknowledged, and valued in the future.

Characterizations of advocacy by practicing nurses

This qualitative descriptive study explored nurses' views of patient advocacy. Seventeen hospital and community nurses were interviewed to determine whether and how they exercise the advocacy role and what they believe promotes or impedes the practice of advocacy. Findings suggested that the advocacy role was not uppermost in the minds of many of the respondents. However, when queried, the nurse-patient relationship emerged as a salient feature of advocacy; teaching, informing, and supporting were frequent activities of nurses in what they described as advocacy; and interpersonal relatedness, rather than issues of accountability and ethics, were central to the advocacy process. Work environment barriers--such as time, economics, acuity, and power hierarchies--combined with factors, such as lack of autonomy and fatigue, to create reasons not to advocate. Physicians contributed to nurses' willingness or unwillingness to advocate depending on their availability, openness to patients and nurses, and their personal demeanor. A conceptual model of client advocacy emerged from the data to guide further explorations of advocacy. The advocacy role is a critical, perhaps unique dimension of professional nursing that is changing rapidly and may be diverging from the usual role prescribed in the professional literature and taught in baccalaureate nursing curricula.

Critical care nurses, ethical decision-making and stress

Considerable attention has focused on describing ethical issues that critical care nurses face in their practice: however, less attention has been directed at describing the process of ethical decision-making. Systematic research linking aspects of ethical-decision making and stress is lacking. This cross-sectional study examines the relationship between selected aspects of ethical decision-making, stress and selected nurse characteristics. Sixty-one critical care nurses completed the Nurse's Ethical Decision Making--ICU Questionnaire and the Health Professions Stress Inventory. Findings revealed that nurses who selected the patient advocacy model had significantly higher nurse autonomy scores, that perceived anxiety had a negative association with nurse autonomy, and that workplace restrictions and stress were related.

Reconnecting: the experiences of nurses caring for hopelessly ill patients in intensive care

The aim of this grounded theory study was to examine the experiences of intensive care nurses caring for patients whom they did not believe were going to survive. Participant observation was undertaken in a large intensive care unit (ICU), and formal unstructured interviews conducted with 14 qualified nurses, in order to discover the nurses' perspectives, dilemmas, and role in caring for hopelessly ill patients and their families. The data were analysed by coding and memos, using a constant comparative analysis. The findings emerged into 11 themes which were condensed into three categories: (i) family separation; (ii) trust; and (iii) family reconnection. The core category is 'reconnecting'; the process by which nurses attempt to overcome the dehumanizing aspects of dying in a technological environment. The context, conditions and consequences of this process are discussed and depicted in a conceptual framework. The conclusions drawn include the idea that nurses require instruction regarding managing death in ICUs to enable as peaceful death as possible, not only for the benefit of the patients and their families, but also for the nurses themselves.