ELEMENTS AND STRATEGIES FOR ETHICAL DECISION-MAKING IN NURSING

Psychometric Evaluation of the Moral Comfort Questionnaire

Background and Purpose: The ethical challenges of the COVID-19 pandemic have contributed to an increase in moral distress (MD) in nurses-a long-standing, ubiquitous issue in nursing-highlighting its detrimental impact on nurses, patients, and healthcare organizations. MD is the negative outcome of a moral situation or dilemma in which a nurse is prevented from taking action on ethical decisions usually related to organizational constraints. On the opposite end of the spectrum, moral comfort (MC), an emerging concept in nursing, is an individual's feelings of ease with decisions and actions related to a moral dilemma or the positive outcome of a moral situation or dilemma. However, nursing literature on MC is sparse. While several instruments to measure MD exist, an instrument to measure MC was not found. The MC Questionnaire (MCQ) was theoretically developed. The purpose of this study was to conduct a psychometric evaluation of the new 35-item MCQ. Methods: Psychometric evaluation design was used. Reliability testing consisted of the examination of internal consistency (coefficient alpha values) and stability (test-retest reliability: Spearman's correlation coefficient, weighted Kappa, and Bland-Altman [B&A] analysis). Validity was examined using content validity (content expert evaluation) and discriminant validity (r < .30). Model fit of a proposed five-factor model was tested using confirmatory factor analysis (CFA). Results: Hospital-based direct-care (HB-DC) registered nurses (RNs; n = 466) participated from February 2019 to September 2019 in this Institutional Review Board-approved study. Participants completed demographic information, the MCQ, and the Moral Distress Scale-Revised (MDSR). The psychometric evaluation included a priori content validation and multiple statistical analyses: coefficient alpha, Spearman's correlation coefficient, weighted Kappa, B&A, discriminant validity, and CFA. Coefficient alpha was .951, suggesting internal consistency. Spearman's correlation coefficient was .605 (p < .001), suggesting a strong correlation between Time 1 and Time 2. Weighted Kappa values for each item (range = .139-.559) suggested slight to moderate agreement between responses over time. The B&A plot suggested agreement of responses over time. Discriminant validity results suggested no correlation between the MCQ and MDSR (r = -.219), which was expected. CFA results suggest a poor model fit of the proposed five-factor model. A post hoc hierarchical cluster analysis showed the presence of two clusters. A subsequent two-factor exploratory factor analysis showed items loading onto one of the two factors (internal and external). Conclusions: MC in nurses is essential to promoting positive outcomes for nurses. An instrument to measure MC in nurses is needed to gain a further understanding of the concept. The MCQ was theoretically developed and psychometrically evaluated. Results suggest the validity and reliability of the MCQ with further testing of a two-factor model. Knowledge acquired from studies using the MCQ could potentially be used to develop strategies to promote MC in nurses, thereby promoting positive outcomes for nurses, patients, and healthcare organizations.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Mapping the core competencies and entrustable professional activities of medical ethics for faculty members

INTRODUCTION

The present study aimed to develop core competencies and Entrustable Professional Activities (EPAs) for faculty members through participating in faculty development programs in medical ethics.

METHODS

This study included five stages. First, categories and subcategories were extracted based on the literature review and interviews with 14 experts and through inductive content analysis. Second, the content validity of the core competency list was checked by 16 experts using qualitative and quantitative approaches. Third, based on the previous phase, a framework for EPAs was developed by the taskforce in two sessions through consensus. Fourth, the content validity of the list of EPAs was compiled based on a three-point Likert 11 medical ethics experts from necessity and relevance perspectives. Fifth, EPAs were mapped by ten experts to the developed core competencies.

RESULTS

After conducting the literature review and interviews, 295 codes were extracted, which were further classified into six categories and 18 subcategories. Finally, five core competencies and 23 EPAs were developed. The core competencies include "Teaching medical ethics", "Research and scholarship in the field of medical ethics", "Communication skills", "Moral reasoning", and "Policy-making, decision-making, and ethical leadership".

CONCLUSION

Medical teachers can be effective in the moralizing healthcare system. Findings showed that faculty members should acquire core competencies and EPAs for proficiently integrating medical ethics into curricula. Faculty development programs can be designed in medical ethics for faculty members to help them to acquire core competencies and EPAs.

Moral distress and moral resilience of nurse managers

BACKGROUND

Moral distress is a phenomenon that can lead to an imbalance of the mind and body. There are many coping strategies to overcome the obstacles that lead the subject to this condition. Some coping strategies are capable of being achieved through the cultivation of moral resilience.

AIM

The aim is to identify the strategies of moral resilience in the nursing management of University Hospitals in Brazil.

RESEARCH DESIGN

The research design is the qualitative study with discursive textual analysis.

PARTICIPANTS AND RESEARCH CONTEXT

: 44 nurse managers and nurses in leadership positions participated in a total of 30 University Hospitals in Brazil. Data were collected online, using a questionnaire with open questions.

ETHICAL CONSIDERATIONS

The Ethics Committee approved the study. Participants received information about the research, agreed to respond to the questionnaire, and were guaranteed anonymity.

FINDINGS

Personal adaptive strategies (intrapersonal and interpersonal) and organizational collaborative strategies (intrinsic and transformational management) emerged from this process. The intrapersonal strategies involved elements of rationality, flexibility, rebalancing practices, moral courage, and detachment. The interpersonal strategies addressed support networks, team involvement, and dialog. Organizational strategies dealt with actions which reorient ethical infrastructure, ethical education, and psychological protection, as well as fostering dialogical relationships, empowerment, and cooperation.

CONCLUSION

From the perspective of social historical construction, it is understood that developing personal and organizational strategies is essential to cultivating moral resilience.

Being torn by inevitable moral dilemma: experiences of ICU nurses

Background

Ethical 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.

Method

The 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.

Results

Being 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.

Conclusions

Results 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.

Into the Grey Zone: Retired Nurses’ Reflections on Ethics in Canadian Nursing Practice

Context: Nurses are often hesitant to talk about ethical issues in their practice for many unique and valid reasons. What if the burden of risk was lifted upon retirement, even if just slightly? The purpose of this study was to explore retired nurses’ reflections on their experiences of ethical issues and decision making in various nursing practice settings throughout their careers and to glean recommendations for ethics in contemporary nursing practice. Methods: Data were collected via in-depth, individual, semi-structured interviews. Guided by an interpretive, descriptive approach, data were managed with NVivo v.11 and analyzed with an inductive, comparative, thematic approach. In northern Ontario, two nurse researchers co-interviewed eight retired nurses with decades of practice experience across diverse Canadian health care settings. Ethics approval was obtained through Lakehead University’s Research Ethics Board. Findings: Three themes emerged to address ethical issues in practice; these are creativity, resourcefulness, and a strong sense of community with other nurses. Further, the retired nurses’ collated reflections on ethics in practice are presented as the FIG model: Fellowship, Ingenuity, and Gumption. Conclusions: This study identifies ethical underpinnings that retired nurses have used to effectively respond to ethical issues in their practice. Those who are currently nursing, and nursing as a profession, may wish to recognize and retain these strategies in order to continue to deliver a high standard of quality, ethical care. Recommendations for practice, research, and education are offered.

Psychometric analysis of the Nurses' Professional Values Scale-3 Arabic version among student nurses

AIMS

We sought to establish the psychometric properties of the Nurses' Professional Values Scale-3 Arabic version among student nurses.

BACKGROUND

Nurses' professional values are central in the nursing profession; it encompasses principles such as respecting people rights and dignity, compassion, and caring without prejudice.

INTRODUCTION

The professional values of student nurses, most specifically in Saudi Arabia and other Arab countries, can hardly be studied due of the lack of a valid and reliable measure that is linguistically and culturally acceptable.

METHODS

In this cross-sectional study, we came up with the Arabic version of the tool and tested its psychometric properties among 350 student nurses from two universities in Saudi Arabia.

RESULTS

The principal component analysis revealed three distinct factors with eigenvalues above 1.00 and with an explained variance of 70.5%. The computed Cronbach's alpha of the tool was 0.967, while 0.964, 0.960, and 0.886 were computed for activism, caring, and professionalism, respectively. The test-retest scores (n = 85) revealed an Intraclass Correlation Coefficient of 0.827 for the entire scale, 0.826 for the subscale activism, 0.792 for caring, and 0.870 for professionalism.

CONCLUSIONS

The Nurses' Professional Values Scale-3 Arabic version had sound psychometric properties when used among Saudi student nurses.

IMPLICATION FOR NURSING

The tool can provide an accurate assessment of the professional values of Saudi nursing students and other Arabic-speaking student nurses.

IMPLICATION FOR NURSING POLICY

The tool can be utilized by nursing and nursing education policymakers in Saudi Arabia and in other Arab countries in guiding the creation of practice and education policies that gears towards improving nurses' professional values in this part of the world.

The effects of debate-based ethics education on the moral sensitivity and judgment of nursing students: A quasi-experimental study

BACKGROUND

While ethics education in undergraduate nursing education can be developed using a variety of teaching and learning strategies, consensus on the content and teaching modules for these ethics courses has still not been established and the effect of ethics education has rarely been evaluated.

OBJECTIVES

The purpose of this study is to compare the effect of debate-based ethics education and lecture-style ethics education on the moral sensitivity and moral judgment of nursing students..

METHODS

This was a pre-test and post-test quasi-experimental study with a control group. A total of 64 senior-year nursing students in Korea participated in the study (35 in the debate group and 29 in the lecture group). The debate-based ethics education lasted for eight weeks with one two-hour session per week. The debate-based ethics education consisted of 16 rounds of affirmative and negative sides. Each debate lasted a total of 40 min and consisted of the introduction, cross-examination, rebuttal, conclusion, operation time, and wrap-up. The outcomes were measured by moral sensitivity and moral judgment questionnaires.

RESULTS

There was a significant improvement in idealistic moral judgment and realistic moral judgment in the debate group compared to the lecture group. However, no statistically significant difference was found for moral sensitivity between the two groups.

CONCLUSION

Based on this study's findings, it can be concluded that the debate-based ethics education for undergraduate nursing students is very effective in promoting moral judgment and the ability to take ethical decisions.

Barriers to ethical decision-making for pre-hospital care professionals

BACKGROUND

Emergency care providers are frequently faces with situations in which they have to make decisions quickly in stressful situations. They face barriers to ethical decision-making and recognizing and finding solutions to these barriers helps them to make ethical decision.

OBJECTIVES

The purpose of this study was to identify barriers of ethical decision-making in Iranian Emergency Medical Service personnel.

METHODS

In this qualitative research, the participants (n = 15) were selected using the purposive sampling method, and the data were collected by deep and semi-structured interviews. Finally, the data are analyzed using the content analysis approach.

ETHICAL CONSIDERATIONS

Permission to conduct the study was obtained from the Ethics Committee of the Shahid Beheshti University of Medical Sciences. The objectives of the study were explained to the participants and written consent was received from them. Also, participants were assured that necessary measures were taken to protect their anonymity and confidentiality.

FINDINGS

The results of the analysis are classified in five main categories. It encompasses the following areas: perception of situation, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes.

CONCLUSION

Emergency Medical Service personnel make ethical decisions every day. It is important that prehospital personnel know how to manage those decisions properly so that clients' moral rights are respected. Hence, by identifying the dimensions and obstacles of ethical decision-making in Emergency Medical Service personnel, it is possible to enhance the moral judgment and ethical accountability of the personnel and develop the strategies necessary for ethical decision-making in them.

Modelo de toma de decisiones bioéticas en ciencias de la salud

La importancia de la toma de decisiones éticas en ciencias de la salud ha promovido la generación de esquemas que orientan este proceso. El objetivo es proponer un modelo teórico de toma de decisiones bioéticas. Se hizo una búsqueda y revisión de la literatura en bases de datos y bibliotecas electrónicas con palabras clave, se identificaron y analizaron once modelos de toma de decisiones éticas según parámetros establecidos y se incluyeron resultados de estudios sobre el tema. Los esquemas analizados plantean una toma de decisiones basada en la razón a partir de un número variable de pasos cognitivos y, en general, aportan pocos elementos para su aplicación práctica. Se planteó el Modelo de Integración Razón Emoción para la Toma de Decisiones Bioéticas en Ciencias de la Salud. Este modelo sintetiza los pasos cognitivos para tomar decisiones adecuadas, mediante la integración de la razón y la emoción, la posibilidad de aplicación de diversos marcos éticos y la puesta en juego de la competencia ética y las habilidades de pensamiento crítico.