A culture of avoidance: voices from inside ethically difficult clinical situations

Psychiatric nurses' experience of moral distress: Its relationship with empowerment and coping

BACKGROUND

Research has shown that moral distress negatively impacts nurses, patients, and organizations; however, several scholars have argued that it can be an opportunity for positive outcomes. Thus, factors that may mitigate moral distress and catalyze positive change need to be explored.

RESEARCH AIM

The purpose of this study was to explore the relationships among structural and psychological empowerment, psychiatric staff nurses' experience of moral distress, and strategies for coping with moral distress.

RESEARCH DESIGN

A descriptive cross-sectional correlational study.

PARTICIPANTS AND RESEARCH CONTEXT

A total of 180 registered nurses working in psychiatric hospitals in Japan participated. This study examined relationships among key variables using four questionnaires to assess structural and psychological empowerment, moral distress for psychiatric nurses, and coping strategies. Statistical analyses of correlations and multiple regressions were conducted.

ETHICAL CONSIDERATIONS

The study was approved by the institutional review board at the author's affiliated university.

FINDINGS

Psychiatric nurses perceived moderate levels of structural and psychological empowerment, and their experiences of moral distress were related to low staffing. Structural empowerment was negatively related to the frequency of moral distress but not the intensity. Contrary to expectations, psychological empowerment was not found to mitigate nurses' moral distress. Multivariate regression analyses revealed that the significant predictors of moral distress were the leaving issues unresolved coping style, the problem-solving coping style, and a lack of formal power, which explained 35% and 22% of the variance in the frequency and intensity of moral distress, respectively.

CONCLUSIONS

In psychiatric hospitals in Japan, nurses experience moral distress that compromises the quality of care they provide. Therefore, formal support for nurses in voicing and investigating their moral concerns is required to bestow formal power by establishing a ward culture that includes shared governance.

Physicians' responses to advanced cancer patients' existential concerns: A video-based analysis

OBJECTIVE

In a recent study, we explored what kind of existential concerns patients with advanced cancer disclose during a routine hospital consultation and how they communicate such concerns. The current study builds on these results, investigating how the physicians responded to those concerns.

METHODS

We analyzed video-recorded hospital consultations involving adult patients with advanced cancer. The study has a qualitative and exploratory design, using procedures from microanalysis of face-to-face-dialogue.

RESULTS

We identified 185 immediate physician-responses to the 127 patient existential utterances we had previously identified. The responses demonstrated three approaches: giving the patient control over the content, providing support, and taking control over the content. The latter was by far the most common, through which the physicians habitually kept the discussion around biomedical aspects and rarely pursued the patients' existential concerns.

CONCLUSIONS

Although the physicians, to some extent, allowed the patients to talk freely about their concerns, they systematically failed to acknowledge and address the patients' existential concerns.

PRACTICE IMPLICATIONS

Physicians should be attentive to their possible habit of steering the agenda towards biomedical topics, hence, avoiding patients' existential concerns. Initiatives cultivating behavior enhancing person-centered and existential communication should be implemented in clinical practice and medical training.

An Evolutionary Concept Analysis of Palliative Care in Oncology Care

This evolutionary concept analysis reports on the concept of palliative care in oncology. Despite its relevance to oncology, the concept of palliative care remains misunderstood, resulting in erroneous interpretations by nurses and health care providers alike. Consequently, integration of palliative care remains heterogeneous and highly contextual. Findings highlight the complexity and ambiguity of the concept of palliative care in the context of oncology care. The nuances and complexity of when to integrate palliative care for patients living with cancer, as well as its evolution from its origins in the hospice movement, have led to its ambiguity in clinical practice.

Quality of work life and working conditions among oncology nurses: A national online descriptive cross-sectional study

The aim of this study was to examine the quality of work life (QoWL) and working conditions of oncology nurses in Turkey. The study utilized a descriptive cross-sectional design. The data were collected via the introductory information form and Brooks' Quality of Nursing Work Life Survey. The study was completed with 138 nurses. The factors affecting QoWL were determined using stepwise multiple linear regression. Nurses had a moderate QoWL, and age, duration of working in nursing, the number of nurses, and the working style were significantly associated with QoWL. To improve the QoWL, the nurses' socio-demographic factors should be considered and working conditions should be improved. Furthermore, well-designed institutional policies should be developed to improve the patient-nurse ratio and provide a quality healthcare.What this paper adds?In the current study, Turkish oncology nurses had a moderate quality of work life.Age, duration of working in the nursing, the number of nurses in the unit and the working style were linked to work-related quality of life in oncology nurses.Well-designed institutional policies should be developed to improve the working conditions and to increase work-related quality of life in oncology nurses.

Development and preliminary validation of a scale to assess physicians’ emotional distress intolerance in end-of-life care communication

Context

End-of-life care (EOLC) communication is beneficial but underutilized, particularly in conditions with a variable course such as chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF). Physicians’ emotional distress intolerance has been identified as a barrier to EOLC communication. However, studies of emotional distress intolerance in EOLC have largely relied on anecdotal reports, qualitative data, or observational studies of physician–patient communication. A free-standing measure of multiple dimensions of distress tolerance is warranted to enable the identification of individuals experiencing distress intolerance and to facilitate the effective targeting of interventions to improve distress tolerance.

Objectives

This study provides preliminary data on the reliability and validity of the Physician Distress Intolerance (PDI) scale. We examine potential subdimensions of emotional distress intolerance.

Method

Family medicine and internal medicine physicians completed the PDI, read vignettes describing patients with COPD or CHF, and indicated whether they initiated or delayed EOLC communication with their patients with similar conditions.

Results

Exploratory and confirmatory factor analyses were performed on separate samples. Confirmatory factor analysis confirmed that a three-factor solution was superior to a two- or one-factor solution. Three subscales were created: Anticipating Negative Emotions, Intolerance of Uncertainty, and Iatrogenic Harm. The full scale and subscales had adequate internal consistency and demonstrated evidence of validity. Higher scores on the PDI, indicating greater distress intolerance, were negatively associated with initiation and positively associated with delay of EOLC communication. Subscales provided unique information.

Significance of results

The PDI can contribute to research investigating and addressing emotional barriers to EOLC communication.

Caring in the silences: why physicians and surgeons do not discuss emergency care and treatment planning with their patients - an analysis of hospital-based ethnographic case studies in England

BACKGROUND

Despite increasing emphasis on integrating emergency care and treatment planning (ECTP) into routine medical practice, clinicians continue to delay or avoid ECTP conversations with patients. However, little is known about the clinical logics underlying barriers to ECTP conversations.

OBJECTIVE

This study aims to develop an ethnographic account of how and why clinicians defer and avoid ECTP conversations, and how they rationalise these decisions as they happen.

DESIGN

A multisited ethnographic study.

SETTING

Medical, orthopaedic and surgical wards in hospitals within four acute National Health Service trusts in England.

PARTICIPANTS

Thirty-four doctors were formally observed and 32 formally interviewed. Following an ethnographic case study approach, six cases were selected for in-depth analysis.

ANALYSIS

Fieldnote data were triangulated with interview data, to develop a 'thick description' of each case. Using a conceptual framework of care, the analysis highlighted the clinical logics underlying these cases.

RESULTS

The deferral or avoidance of ECTP conversations was driven by concerns over caring well, with clinicians attempting to optimise both medical and bedside practice. Conducting an ECTP conversation carefully meant attending to patients' and relatives' emotions and committing sufficient time for an in-depth discussion. However, conversation plans were often disrupted by issues related to timing and time constraints, leading doctors to defer these conversations, sometimes indefinitely. Additionally, whereas surgeons and geriatricians deferred conversations because they did not have the time to offer detailed discussions, emergency and acute medicine clinicians deferred conversations because the high-turnover ward environment, combined with patients' acute conditions, meant triaging conversations to those most in need.

CONCLUSION

Overcoming barriers to ECTP conversations is not simply a matter of enhancing training or hospital policies, but of promoting good conversational practices that take into account the affordances of hospital time and space, as well as clinicians' understandings of caring well.

Care for critically and terminally ill patients and moral distress of physicians and nurses in tertiary hospitals in South Korea: A qualitative study

Physicians and nurses working in acute care settings, such as tertiary hospitals, are involved in various stages of critical and terminal care, ranging from diagnosis of life-threatening diseases to care for the dying. It is well known that critical and terminal care causes moral distress to healthcare professionals. This study aimed to explore moral distress in critical and terminal care in acute hospital settings by analyzing the experiences of physicians and nurses from various departments. Semi-structured in-depth interviews were conducted in two tertiary hospitals in South Korea. The collected data were analyzed using grounded theory. A total of 22 physicians and nurses who had experienced moral difficulties regarding critical and terminal care were recruited via purposive maximum variation sampling, and 21 reported moral distress. The following points were what participants believed to be right for the patients: minimizing meaningless interventions during the terminal stage, letting patients know of their poor prognosis, saving lives, offering palliative care, and providing care with compassion. However, family dominance, hierarchy, the clinical culture of avoiding the discussion of death, lack of support for the surviving patients, and intensive workload challenged what the participants were pursuing and frustrated them. As a result, the participants experienced stress, lack of enthusiasm, guilt, depression, and skepticism. This study revealed that healthcare professionals working in tertiary hospitals in South Korea experienced moral distress when taking care of critically and terminally ill patients, in similar ways to the medical staff working in other settings. On the other hand, the present study uniquely identified that the aspects of saving lives and the necessity of palliative care were reported as those valued by healthcare professionals. This study contributes to the literature by adding data collected from two tertiary hospitals in South Korea.

Moral Distress in Hospitals During the First Wave of the COVID-19 Pandemic: A Web-Based Survey Among 3,293 Healthcare Workers Within the German Network University Medicine

Objective: The present study aimed to investigate the correlation between moral distress and mental health symptoms, socio-demographic, occupational, and COVID-19-related variables, and to determine differences in healthcare workers’ (HCW) moral distress during the first wave of the COVID-19 pandemic.

Method: Data from 3,293 HCW from a web-based survey conducted between the 20th of April and the 5th of July 2020 were analyzed. We focused on moral distress (Moral Distress Thermometer, MDT), depressive symptoms (Patient Health Questionnaire-2, PHQ-2), anxiety symptoms (Generalized Anxiety Disorder-2, GAD-2), and increased general distress of nurses, physicians, medical-technical assistants (MTA), psychologists/psychotherapists, and pastoral counselors working in German hospitals.

Results: The strongest correlations for moral distress were found with depressive symptoms, anxiety symptoms, occupancy rate at current work section, and contact with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Nurses and MTA experienced significantly higher moral distress than physicians, psychologists/psychotherapists, and pastoral counselors. The average level of moral distress reported by nurses from all work areas was similar to levels which before the pandemic were only experienced by nurses in intensive or critical care units.

Conclusion: Results indicate that moral distress is a relevant phenomenon among HCW in hospitals during the COVID-19 pandemic, regardless of whether they work at the frontline or not and requires urgent attention.

Expert nurses' coping strategies in ethically challenging situations: a qualitative study

BACKGROUND

Nurses frequently encounter ethically challenging situations in everyday practice. In these situations, nurses often know an appropriate course of action to take but are unable to do so. Many studies have examined the ethically challenging situations faced by nurses, but how nurses cope with these situations is not well understood. Therefore, this study aims to explore the coping strategies used or adopted in ethically challenging situations by expert nurses in South Korea.

METHODS

Participants were recruited via purposive sampling. Small group interviews were conducted with 26 expert registered nurses in a general hospital in South Korea. The data were analyzed using Giorgi's descriptive phenomenological method.

RESULTS

The essential theme of nurses' experience of coping with ethically challenging situations was "being faithful to the nature of caring." This essential theme comprised three themes: self-monitoring of ethical insensitivity, maintaining honesty, and actively acting as an advocate.

CONCLUSIONS

The findings of this study suggest that the coping strategies of expert nurses are mostly consistent with the attributes of ethical competence as previously defined in healthcare, and expert nurses can address ethically challenging situations in an effective and ethical manner by faithfully adhering to the spirit of caring. System-wide early counseling and interventions should be considered for nurses who have experienced ethical difficulties.

Clinician distress in seriously ill patient care: A dimensional analysis

BACKGROUND

Caring for patients with serious illness may severely strain clinicians causing distress and probable poor patient outcomes. Unfortunately, clinician distress and its impact historically has received little attention.

RESEARCH PURPOSE

The purpose of this article was to investigate the nature of clinician distress.

RESEARCH DESIGN

Qualitative inductive dimensional analysis.

PARTICIPANTS AND RESEARCH CONTEXT

After review of 577 articles from health sciences databases, a total of 33 articles were eligible for analysis.

ETHICAL CONSIDERATIONS

This study did not require ethical review and the authors adhered to appropriate academic standards in their analysis.

FINDINGS

A narrative of clinician distress in the hospital clinician in the United States emerged from the analysis. This included clinicians' perceptions and sense of should or the feeling that something is awry in the clinical situation. The explanatory matrix consequence of clinician distress occurred under conditions including: the recognition of conflict, the recognition of emotion, or the recognition of a mismatch; followed by a process of an inability to feel and act according to one's values due to a precipitating event.

DISCUSSION

This study adds three unique contributions to the concept of clinician distress by (1) including the emotional aspects of caring for seriously ill patients, (2) providing a new framework for understanding clinician distress within the clinician's own perceptions, and (3) looking at action outside of a purely moral lens by dimensionalizing data, thereby pulling apart what has been socially constructed.

CONCLUSION

For clinicians, learning to recognize one's perceptions and emotional reactions is the first step in mitigating distress. There is a critical need to understand the full scope of clinician distress and its impact on the quality of patient-centered care in serious illness.

An Ethics Early Action Protocol to Promote Teamwork and Ethics Efficacy

BACKGROUND

Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress.

OBJECTIVES

The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points.

METHODS

Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used.

RESULTS

At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly.

DISCUSSION

This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout.

Mindful Ethical Practice and Resilience Academy: Equipping Nurses to Address Ethical Challenges

BACKGROUND

Ethical challenges in clinical practice significantly affect frontline nurses, leading to moral distress, burnout, and job dissatisfaction, which can undermine safety, quality, and compassionate care.

OBJECTIVES

To examine the impact of a longitudinal, experiential educational curriculum to enhance nurses' skills in mindfulness, resilience, confidence, and competence to confront ethical challenges in clinical practice.

METHODS

A prospective repeated-measures study was conducted before and after a curricular intervention at 2 hospitals in a large academic medical system. Intervention participants (192) and comparison participants (223) completed study instruments to assess the objectives.

RESULTS

Mindfulness, ethical confidence, ethical competence, work engagement, and resilience increased significantly after the intervention. Resilience and mindfulness were positively correlated with moral competence and work engagement. As resilience and mindfulness improved, turnover intentions and burnout (emotional exhaustion and depersonalization) decreased. After the intervention, nurses reported significantly improved symptoms of depression and anger. The intervention was effective for intensive care unit and non-intensive care unit nurses (exception: emotional exhaustion) and for nurses with different years of experience (exception: turnover intentions).

CONCLUSIONS

Use of experiential discovery learning practices and high-fidelity simulation seems feasible and effective for enhancing nurses' skills in addressing moral adversity in clinical practice by cultivating the components of moral resilience, which contributes to a healthy work environment, improved retention, and enhanced patient care.

Transition to comfort-focused care: Moral agency of acute care nurses

BACKGROUND

Moving into the last phase of life comprises a developmental transition with specific needs and risks. Facilitating transitions is an important component of the work of nurses. When curative interventions are no longer helpful, nurses enact key roles in caring for patients and families.

AIM

The aim of this study was to examine the experiences of registered nurses in acute care settings as they worked with patients and families to facilitate transition to comfort-focused care.

RESEARCH DESIGN

Sampling, data collection, and data analysis were guided by constructivist grounded theory, chosen because of its strength in identifying and explicating social processes.

PARTICIPANTS AND CONTEXT

A purposeful sample of 26 registered nurses working in acute care hospitals in one community in the northeastern United States participated in this study through semi-structured interviews.

ETHICAL CONSIDERATIONS

The study received approval from the university's Institutional Review Board for the Protection of Human Subjects. Participants provided informed consent.

FINDINGS

Nurses facilitated transition to comfort-focused care by enacting their moral commitments to patients and families. They focused on building relationships, honoring patient self-determination, and maintaining respect for personhood. In this context, they discerned a need for transition, opened a discussion, and used diverse strategies to facilitate achieving consensus on the part of patients, family members, and care providers. Regardless of how the process unfolded, nurses offered support throughout.

DISCUSSION

Achievement of consensus by all stakeholders is critical in the transition to comfort-focused care. This study deepens our understanding of how nurses as moral agents utilize specific strategies to assist progress toward consensus. It also offers an example of recognizing the moral agency of nurses through listening to their voices.

CONCLUSION

Increased understanding of effective nursing strategies for facilitating transition to comfort-focused care is essential for developing needed evidence for excellent care and strengthening end-of-life nursing education.

Giving nurses a voice during ethical conflict in the ICU

BACKGROUND

Ethical conflict and subsequent nurse moral distress and burnout are common in the intensive care unit. There is a gap in our understanding of nurses' perceptions of how organizational resources support them in addressing ethical conflict in the intensive care unit.

RESEARCH QUESTION/OBJECTIVES/METHODS

The aim of this qualitative, descriptive study was to explore how nurses experience ethical conflict and use organizational resources to support them as they address ethical conflict in their practice.

PARTICIPANTS AND RESEARCH CONTEXT

Responses to two open-ended questions were collected from critical care nurses working in five intensive care units at a large, academic medical center in the Midwestern region of the United States.

ETHICAL CONSIDERATIONS

This study was approved by the Institutional Review Board at the organization where the study took place.

FINDINGS

Three main interwoven themes emerged: nurses perceive (1) intensive care unit culture, practices, and organizational priorities contribute to patient suffering; (2) nurses are marginalized during ethical conflict in the intensive care unit; and (3) organizational resources have the potential to reduce nurse moral distress. Nurses identified ethics education, interprofessional dialogue, and greater involvement of nurses as important strategies to improve the management of ethical conflict.

DISCUSSION

Ethical conflict related to healthcare system challenges is intrinsic in the daily practice of critical care nurses. Nurses want to be engaged in discussions about their perspectives on ethical conflict and play an active role in addressing ethical conflict in their practice. Organizational resources that support nurses are vital to the resolution of ethical conflict.

CONCLUSION

These findings can inform the development of interventions that aim to proactively and comprehensively address ethical conflict in the intensive care unit to reduce nurse moral distress and improve the delivery of patient and family care.

Relationships among Climate of Care, Nursing Family Care and Family Well-being in ICUs

BACKGROUND

Frequent exposure to ethical conflict and a perceived lack of organizational support to address ethical conflict may negatively influence nursing family care in the intensive care unit.

RESEARCH AIMS

The specific aims of this study were to determine: (1) if intensive care unit climate of care variables (ethical conflict, organizational resources for ethical conflict, and nurse burnout) were predictive of nursing family care and family wellbeing and (2) direct and indirect effects of the climate of care on the quality of nursing family care and family wellbeing.

RESEARCH DESIGN

A cross-sectional, correlational design was used.

PARTICIPANTS AND RESEARCH CONTEXT

Convenience sample of 111 nurses and 44 family members from five intensive care units at a Midwest hospital in the United States.

INSTRUMENTS

The Ethical Conflict Questionnaire-Critical Care Version, Maslach Burnout Inventory-Human Services Survey and Hospital Ethical Climate Scale were used to measure climate of care. The Family-Centered Care-Adult Version and Nurse Provided Family Social Support Scale were family measures of the quality of nursing family care. The Family Wellbeing Index was used to measure family wellbeing.

DATA ANALYSIS

Hierarchical regression and mediation analysis were used to answer the study aims.

ETHICAL CONSIDERATIONS

The study was approved by the Institutional Review Board at the study site.

FINDINGS

In separate regression models, organizational resources for ethical conflict (β = .401, p = .006) and depersonalization (β = -.511, p = .006), a component of burnout, were significant predictors of family-centered care. In simple mediation analysis the relationship between organizational resources for ethical conflict and family-centered care was mediated by depersonalization (β = .341, 95% confidence interval (.015, .707)).

DISCUSSION

Inadequate organizational resources and depersonalization may be related to family care delivery, and present obstacles to family-centered care in the intensive care unit.

CONCLUSION

Further research to explicate the relationships among organizational resources, ethical conflict, burnout, and family-centered care is needed to guide the development of effective interventions that enhance the quality of nursing family care in the intensive care unit.

Moral Distress, Sign of Ethical Issues in the Practice of Oncology Nursing: Literature Review

Objective: To describe the factors that influence the emergence of moral distress in oncology nurses. Methodology: integrative review of the literature whose search will be performed in Web of Science databases, CINAHL (EBSCO), Scielo, Proquest, Pubmed and PsycInfo using the keywords moral distress and oncology nursing and their similes in Spanish, without restriction for years of publication until 2017. Results: The results of this review were grouped into three groups of factors each with subgroups: 1) Organizational factors: ethical climate, evasive culture and resources for ethics delivered by the organization. 2) Particular clinical situations: pain management, information delivery, futile treatment, and assistance to the patient and their family in the process of death, 3) Interpersonal relationships: poor communication, power relations, trust in the team’s competence. Conclusion: the three factors described are triggers of moral distress in oncology nurses. When there are ethical problems and the nurses do not participate in the deliberation process, these problems can be hidden and be normalized, which can diminish the moral sensitivity of the professionals, as well as the possibility of acting as moral agents.

Why Are There So Few Ethics Consults in Children's Hospitals?

In most children's hospitals, there are very few ethics consultations, even though there are many ethically complex cases. We hypothesize that the reason for this may be that hospitals develop different mechanisms to address ethical issues and that many of these mechanisms are closer in spirit to the goals of the pioneers of clinical ethics than is the mechanism of a formal ethics consultation. To show how this is true, we first review the history of collaboration between philosophers and physicians about clinical dilemmas. Then, as a case-study, we describe the different venues that have developed at one children's hospital to address ethical issues. At our hospital, there are nine different venues in which ethical issues are regularly and explicitly addressed. They are (1) ethics committee meetings, (2) Nursing Ethics Forum, (3) ethics Brown Bag workshops, (4) PICU ethics rounds, (5) Grand Rounds, (6) NICU Comprehensive Care Rounds, (7) Palliative Care Team (PaCT) case conferences, (8) multidisciplinary consults in Fetal Health Center, and (9) ethics consultations. In our hospital, ethics consults account for only a tiny percentage of ethics discussions. We suspect that most hospitals have multiple and varied venues for ethics discussions. We hope this case study will stimulate research in other hospitals analyzing the various ways in which ethicists and ethics committees can build an ethical environment in hospitals. Such research might suggest that ethicists need to develop a different set of "core competencies" than the ones that are needed to do ethics consultations. Instead, they should focus on their skills in creating multiple "moral spaces" in which regular and ongoing discussion of ethical issues would take place. A successful ethicist would empower everyone in the hospital to speak up about the values that they believe are central to respectful, collaborative practice and patient care. Such a role is closer to what the first hospital philosophers set out to do than in the role of the typical hospital ethics consultant today.

Shared decision-making at the end of life: A focus group study exploring the perceptions and experiences of multi-disciplinary healthcare professionals working in the home setting

BACKGROUND

Globally recommended in healthcare policy, Shared Decision-Making is also central to international policy promoting community palliative care. Yet realities of implementation by multi-disciplinary healthcare professionals who provide end-of-life care in the home are unclear.

AIM

To explore multi-disciplinary healthcare professionals' perceptions and experiences of Shared Decision-Making at end of life in the home.

DESIGN

Qualitative design using focus groups, transcribed verbatim and analysed thematically.

SETTING/PARTICIPANTS

A total of 43 participants, from multi-disciplinary community-based services in one region of the United Kingdom, were recruited.

RESULTS

While the rhetoric of Shared Decision-Making was recognised, its implementation was impacted by several interconnecting factors, including (1) conceptual confusion regarding Shared Decision-Making, (2) uncertainty in the process and (3) organisational factors which impeded Shared Decision-Making.

CONCLUSION

Multiple interacting factors influence implementation of Shared Decision-Making by professionals working in complex community settings at the end of life. Moving from rhetoric to reality requires future work exploring the realities of Shared Decision-Making practice at individual, process and systems levels.

When a Patient Is Reluctant To Talk About It: A Dual Framework To Focus on Living Well and Tolerate the Possibility of Dying

Many patients with serious illness struggle to talk about the possibility of dying; yet basic prognostic awareness is crucial for informed decision making. In this article, we aim to help outpatient clinicians working with seriously ill patients ambivalent, uncomfortable, or fearful of further discussion about the future. We describe a dual framework that focuses on living well while acknowledging the possibility of dying and equips clinicians to help patients hold both possibilities. This dual framework facilitates the developmental process of living as fully as possible while also preparing for the possibility of dying.

Living with life-prolonging chemotherapy-control and meaning-making in the tension between life and death

Chemotherapy, radiotherapy, hormone therapy and immune therapy have made many cancers chronic, potential curable diseases rather than inevitably fatal, but the treatments are often both mentally and physically stressful even if the side effects varies. The right use of palliative chemotherapy is a complex issue and there are many aspects to take into consideration. The aim of the study was to gain insight into the illness narratives of cancer patients, from the day they suspected that something was wrong up to the present day where they are living with incurable cancer, undergoing life-prolonging chemotherapy. Thirteen narrators were included. They were all cancer patients on chemotherapy with the intention of prolonging life (informed by their oncologist) in an outpatient's clinic in Norway. Narrative analyse of their illness stories was applied. The main findings showed that the narrators considered their lives worth living in spite of the treatment. They seemed to take control and build a new life on "what was left after the storm," and described how they found meaning living in the tension between life and death.

Moral Distress in Nurses Providing Direct Patient Care at an Academic Medical Center

BACKGROUND

Moral distress is the psychological response to knowing the appropriate action but not being able to act due to constraints. Previous authors reported moral distress among nurses, especially those that work in critical care units.

AIMS

The aims of this study were: (1) to examine the level of moral distress among nurses who work at an academic health system, (2) to compare the level of moral distress in nurses who work across specialty units at an academic health system, (3) to compare moral distress by the demographic characteristics of nurses and work experience variables, and (4) to identify demographic characteristics and type of clinical setting that may predict which nurses are at high risk for moral distress.

METHODS

A cross-sectional survey design was used with staff nurses who work on inpatient units and ambulatory units at an academic medical center. The moral distress scale-revised (MDS-R) was used to assess the intensity and frequency of moral distress.

RESULTS

The overall mean MDS-R score in this project was low at 94.97 with mean scores in the low to moderate range (44.57 to 134.58). Nurses who work in critical care, perioperative services, and procedure areas had the highest mean MDS-R scores. There have been no previous reports of higher scores for nurses working in perioperative and procedure areas. There was weak positive correlation between MDS-R scores and years of experience (Rho = .17, p = .003) but no correlation between age (Rho = .02, p = .78) or education (Rho = .05, p = .802) and moral distress.

LINKING EVIDENCE TO ACTION

Three variables were found useful in predicting moral distress: the type of unit and responses to two qualitative questions related to quitting their job. Identification of these variables allows organizations to focus their interventions.

Unmet Needs for Clinical Ethics Support Services in Nurse: Based on focus group interviews

BACKGROUND

As nurses' ethical competence in their own fields is essential, clinical ethics support services help nurses improve ethical competence.

OBJECTIVES

The purpose of this study was to identify the unmet needs of ethical support for nurses in clinical settings and explore the differences by nursing units.

RESEARCH DESIGN

Focus group interview design was applied. Participants and research context: Data were collected via four rounds of focus group interviews with 37 nurses at intensive care units, medical-surgical units, emergency departments and oncology units. Major questions were as follows: 'What is nurses' experience of ethical difficulties while working as a clinical nurse?' and 'What kinds of clinical ethics support services do nurses require in different clinical settings?' Inductive content analysis was performed to analyse the data. Ethical considerations: Ethical approval was obtained from the institutional review of board at the College of Nursing.

FINDINGS

Five categories (with 14 subcategories) were identified: difficulty providing evidence-based care, lack of support in maintaining patients' and family members' dignity, insufficient education regarding clinical ethics, loss of professional self-esteem and expectations concerning organizational support. Nurses' desire for ethical support varied according to department.

CONCLUSION

Nurses face both practical and existential ethical issues that require rapid solution each day. There is a need for ethical counselling to prevent compassion fatigue and identify means via which nurses reflect on their daily lives in their own fields. In-house training should be provided for each unit, to improve ethical competence and facilitate the development of pragmatic, sensible solutions.