Moral conflicts from the justice and care perspectives of japanese nurses: a qualitative content analysis

BACKGROUND

Healthcare professionals use the ethics of justice and care to construct moral reasoning. These ethics are conflicting in nature; different value systems and orders of justice and care are applied to the cause of actual moral conflict. We aim to clarify the structure and factors of healthcare professionals' moral conflicts through the lens of justice and care to obtain suggestions for conflict resolutions.

METHOD

Semi-structured interviews about experiences of moral conflict were conducted with Japanese nurses recruited using the snowball sampling method. Interviews were conducted based on the real-life moral conflict and choice interview. Interviews were recorded and transcribed verbatim, then analyzed based on the interpretive method of data analysis. Verbatim transcripts were read four times, first to get an overall sense of the conflict, then to understand the person's thoughts and actions that explain the conflict, and third and fourth to identify perspectives of justice and care, respectively. Each moral perspective was classified into categories according to Chally's taxonomy.

RESULTS

Among 31 responses, 2 that did not mention moral conflict were excluded, leaving 29 responses that were analyzed. These responses were classified into six cases with conflict between both justice and care perspectives or within one perspective, and into two cases without conflict between perspectives. The "rules" category of justice and the "welfare of others" category of care were included in many cases of conflict between two perspectives, and they frequently occurred in each perspective.

CONCLUSIONS

The nurses in this study suggest that they make moral judgments based on moral values that are intertwined with justice and care perspectives complex manner.Organizational, professional, and patient-related factors influenced conflicts between justice and care. Additionally, multiple overlapping loyalties created conflicts within justice perspectives, and multifaceted aspects of care-provider's responsibility and patient need created conflicts within care. Decision-making biased towards one perspective can be distorted. It is important to consider ethical issues from both perspectives to resolve conflicts, especially the effective use of the ethics of care is recommended.

Ethical Issues Encountered by Forensic Psychiatric Nurses in Japan

BACKGROUND

Criminals in Japan with mental disorders face penal servitude in prison or treatment under the Medical Treatment and Supervision Act, depending on their ability to take responsibility for their criminal acts. Forensic psychiatric nurses caring for this group may face various ethical issues.

OBJECTIVE

This study aimed to identify ethical issues forensic psychiatric nurses in Japan encountered.

METHOD

We used the Ethical Issues Scale to conduct a survey among forensic healthcare ward nurses and analyzed the data using descriptive statistics. We also conducted semistructured interviews with individual nurses who provided signed consent and responded to the initial survey on ethical issues they encountered. These data were analyzed using Berelson's content analysis.

RESULTS

Of 175 nurses, 131 answered our survey. The most frequently encountered ethical issue was "protecting patients' rights and human dignity," and the most disturbing ethical issue was "providing nursing care with possible health risks." Seventy-seven percent of the nurses chose to discuss with peers when resolving the ethical issues. Seventeen nurses who were interviewed described these forensic psychiatric nursing-related ethical distresses and conflicts: difficulty in discharge management, prevention of violence and self-harm, compulsory treatment, patient care, and negative emotions toward patient.

CONCLUSION

Forensic psychiatric nurses in Japan face difficulties regarding respecting patients' rights. They strive to respect patients' rights by using their expertise as nurses while sharing their difficulties with colleagues. It is important to develop a support system for social reintegration to solve ethical issues.

[Surgical contrivance for bronchoplasty; U-shape mattress interrupted suture with pledgets]

There are some nuisance complications concerning inadequate adaptation of the anastomosis after bronchoplasty, such as air leakage, stenosis and granulation. These causative factors could be that the cartilaginous portion, which depend on diffusion from the submucosal capillary plexus, was used for the anastomosis stump and suture materials lingered on the anastomosis line. In this time for the aim to avoid these potential problems we used the mucosa surface, which was supplied by abundant vessele, for an extroversional mattress suture. Therefore we contrived a new technique, U-shape mattress interrupted suture (mucosa extroversional suture) using 3-0 PDS or Maxon with pledgets. It enables to make both enough margins of the bronchial mucosa surfaces touch tightly and to prevent sutures from lacerating the graft during using knot pusher. We have performed this procedure to 8 times in 7 cases (sleeve lobectomy 3, sleeve segmentectomy 1, bronchial resection 2, lobectomy + bronchial wedge plasty 2) and could acquire excellent outcome.

[Contrivance for video-assisted thoracic surgery pulmonary resection; a new-shaped rib spreader and one port operatinon]

A new-shaped rib spreader, which was adapted from a ready-made reverse arch rib spreader, was orderd to consist of inverted-Y-shape blades which were 4 cm in length, 3.7 cm in width and bent at 250 angle with each other at the half of length. This rib spreader with long and angled blades make it possible to perform video-assisted thoracic surgery (VATS) lobectomy and segmentectomy with 4-5 cm access incision and only 1 port for almost all of the patients inclusive of a thick chest wall case. A lung grasping forceps and a thoracoscope together were inserted from the same port insicion. The surgeon operates by watching both monitoring vision and direct vision through the access incision. Pulmonary artery (PA) s were ligated by double tied and transfixion suture with silk threads. Pulmonary vein (PV) s and bronchus were stapled and divided with Endo-GIA. Lymph nodes division was performed for ND2a-2b in right side, however, ND2a in left side. These thoracoscopic pulmonay resectional procedure can be performed safely, certainly, cosmeticaly and for reducing cost.

[Surgical treatment for locally advanced lung cancer; therapeutic response of induction chemotherapy and postoperative chemotherapy]

The current chemotherapy has been able to give us many options to treat for lung cancer and recent studies have showed that perioperative chemotherapy may improve survival. In this study, we compared 2 groups with locally advanced lung cancers (stage III, T3N0M0, inclusive of ipsilateral PM2, D1 and D2) ; group A, which had been treated by chemotherapy for downstaging prior to surgery (n = 23), and group B, which had been treated by surgery alone (n = 48). The postoperative 3- and 5-year overall survival rates analyzed using the Kaplan-Meier method were 64.7 and 29.4% for group A, 32.5 and 10% for group B, respectively. And there was a significant difference between 2 groups. Further on patients with pN2, 3-year survival rate was 60% for group A and 36.7% for group B. In view of the progress of chemotherapy, even if the locally advanced lung cancer, which may be suspected of invasion to pulmonary artery, pulmonary vein and central bronchus, is not classified as T4, a patient with it should be performed an induction chemotherapy for downstaging and an operation for complete resection of the tumor and preserving lung function.

[Lung carcinomas with interstitial pneumonia; detection of lung cancers by CYFRA and selection of surgical procedure]

Interstitial pneumonia (IP) may occur with the chest radiographic abnormality at the bilateral, predominantly basal and subpleural area of the lower lobe. And the incidence of lung cancer are markedly increased among patients with IP. From 1993 to 2003, 15 cases (male 14, female 1; average age 65.9-year-old), who were complicated IP, underwent surgical treatment in our hospital. Concerning detective tumor markers of lung cancers with IP, CYFRA showed very high sensitivity (92.3%) for any type of carcinoma. There were no case of perioperative death, however, 3 cases occurred severe deterioration of IP within 1 month and 6 cases died of respiratory failure. The risk factors, which aggravated IP at the postoperative period, were administration of prednisolone or immunosuppressive drugs from pre-operation and resection of the relatively non-fibrotic and non-honeycomb lobe which was affected with cancer. If it is possible to prognosticate the postoperative deterioration of IP, segmentectomy should be considered.

Three-year follow-up study of allergy in workers in a mushroom factory

Exposure to mushroom spores may cause many respiratory allergic diseases, however, there has been no serial study in a mushroom factory to address this problem. The aim of this study was to investigate the serial changes in respiratory allergy and the incidence of hypersensitivity pneumonitis (HP) in mushroom workers. A 3-year follow-up study, beginning in June 1996, was conducted in a newly operating mushroom factory in which one kind of mushroom is produced: Hypsizigus marmoreus (Bunashimeji). Allergic symptoms, chest roentgenogram, serum precipitins to the spores and soluble adhesion molecules in sera were evaluated once a year in 60 workers and 20 controls. Three out of the 60 subjects were diagnosed as having HP caused by inhalation ofthe mushroom spore and they were therefore excluded from this study, and the 57 non-HP subjects were evaluated. In this study 24 workers quit because of intolerable cough, runny nose, wheezing, sputum, fever elevation and/or shortness of breath at their place of work. During each year of this study as many as 70-80% of employees suffered some ofthe above symptoms, cough being the most frequent, and positive rate of serum precipitins to the spore revealed 30% in 1996, 93% in 1997 and 94% in 1998. From the June 1996 examination until the following May, serum soluble intercellular adhesion molecule-1 levels of the 15 workers who quit during that period were significantly higher than those in the 42 workers still employed in 1997 (P < 0.05). Workers in Bunashimeji mushroom factories might be at critical risk of developing respiratory allergy. In our 3-year study over 90% workers were sensitized to the spore, 40% quit because of the symptoms and 5% developed HP. It was suggested that workers should be counselled about the risk of mushroom allergy and precautionary measures should be taken to prevent its occurrence.

Chronic hypersensitivity pneumonitis induced by Shiitake mushroom spores associated with lung cancer

A 61-year-old man was admitted to our hospital with a 6-month history of productive cough. He, along with his wife, had been involved with Shiitake mushroom cultures for a period of 12 years. On admission, chest radiography showed bilateral fine-nodular shadow and CT scans showed reticulonodular opacities and a ground-glass appearance predominantly in the subpleural area in both lungs, and a mass in the left S6. Resected pathological specimens obtained by left lower lobectomy revealed lung adenosquamous carcinoma (stage IB), interstitial changes accompanied with lymphocyte proliferation and fibrosis, and granuloma with giant cells. Serum precipitins for Shiitake mushroom antigens were positive. The productive cough improved after the hospital admission and occurred again when he returned to work with the Shiitake mushroom production. Therefore, chronic hypersensitivity pneumonitis (HP) caused by Shiitake mushroom spores was diagnosed. Moreover, his wife was found to have HP caused by mushrooms at this time. There are only two previous reports of chronic HP caused by Shiitake mushroom in Japan, and this is the first case of chronic HP associated with lung cancer.

[The use of the autologous blood transfusion to the respiratory surgery: autologous blood transfusion or no-blood transfusion surgery?]

We could report the effect of the autologous blood transfusion to the lobectomy, by comparison with no-blood transfusion group and MAP-red cell concentrate transfused group (MAP group). Autologous blood which was stored three days before an operation and preserved at 4 degrees C kept 89.9 +/- 11.7% of the number of erythrocyte and 59.6 +/- 23.4% of platelet. Autologous blood transfusion group and MAP group showed significantly more than no-blood transfusion group on the number of erythrocyte at the time of discharge. These facts suggest that the autologous blood has an ability of coagulation. We concluded that on lobectomy autologous blood transfusion was better than MAP-red cell concentrate transfusion in point of protection from disease transmission and better than no-blood transfusion in point of post-operative recovery.

[Limited thoracotomy as surgical therapy for lung cancer: lobectomy and lymph node dissection by means of 12 cm skin incision]

In the domain of respiratory surgery minimally invasive approaches are currently being used and video-assisted thoracic surgery (VATS) is one of these methods. However VATS has some problems in its use for malignant lung diseases for example, with VATS adequate lymph node dissection and continuation of lobectomy in cases with severe adhesion are both difficult. In consideration of these points, limited thoracotomy has been practiced for treatment of lung cancer in our hospital. This study made comparisons between this new method (group A) and the conventional standard thoracotomy (group B). For the limited thoracotomy group (A) the skin incision and amount of bleeding were smaller than for the standard thoracotomy group (B) and the operation time was shorten. All limited thoracotomy group patients could lift up and move the hand of the affected side without pain immediately after the operation. The limited thoracotomy is an excellent approach as a curative operation for lung cancer, for preservation of post-operative pulmonary function, for movement capacity of the hand of the affected side and from the cosmetic viewpoint.

[The estimation of the effectiveness of GRF glue in the respiratory]

We had reported on the basis of experimental findings that the efficacy of protecting the suture line in tracheoplasty by using a self-fascia lata and GRF glue. This time we investigated the effectiveness of GRF glue in the respiratory surgery on the basis of clinical findings. All ten cases in which GRF glue was used resulted in an excellent outcome, namely, GRF glue prevented from air leakage, bleeding and leakage of chyle. Moreover, it was not recognized that any grave side effects occurred in any cases after using GRF glue. We could conclude that GRF glue was a useful material for the respiratory surgery, especially for the case that had a dead space after lobectomy. However its price is not inexpensive, therefore, there seems need to restrict the use of GRF glue--for example--to cases of Giant bulla resection, residual of a large dead space as a postoperative possibility and chemotherapy performed before an operation, and so on.

[A case of pulmonary carcinoma removed safely from SVC by using CUSA]

A 50-year-old man, who had his medical history of right pulmonary tuberculosis, was pointed out an abnormal shadow in the right upper mediastinum on the chest X-ray. Chest CT scan demonstrated a large tumor mass that was suspected to make partial invasions upon the great vessels (SVC and right PA). We could perform a safety removal of the tumor from the great vessels without perforation of vessels by using CUSA. The output of CUSA was set up 20-30% of the maximum (amplitude; 60-90 microns). The tumor came from rS2 and rS3 and was large cell carcinoma. Nevertheless taking a time, CUSA is a useful device for a bleeding-less tumor removal.

Mushroom worker's lung caused by spores of Hypsizigus marmoreus (Bunashimeji): elevated serum surfactant protein D levels

This is a report on two patients with occupational hypersensitivity pneumonitis (HP) caused by spores of Hypsizigus marmoreus (Bunashimeji) and serial follow-up measurements of serum surfactant protein D (SP-D) levels. The diagnosis of HP was confirmed immunologically by the detection of serum precipitins to spores of Bunashimeji, but not to other antigens, and by the positive results of in vitro lymphocyte proliferative response for Bunashimeji antigens using BAL fluid lymphocytes. This is the first case report of HP caused by Bunashimeji. Serum SP-D levels for the two patients (493 and 226 ng/mL; cut off level, 110 ng/mL) were elevated at diagnosis and decreased after separation from antigens following corticosteroid therapy. However, in one patient who returned to the same job, the symptoms appeared again and SP-D level also increased.

Idiopathic saccular azygos vein aneurysm

We present a case of asymptomatic saccular aneurysm of the azygos vein. This abnormality is exceedingly rare. Dynamic computed tomography revealed strong enhancement of the mass, suggesting a vascular structure, which was very important for preoperative diagnosis. It is unclear whether the mass should be resected if the preoperative diagnosis has been made and the mass is not so large.

[A case of chronic interstitial pneumonia with benign monoclonal gammopathy (IgM-k) and thrombocytopenia]

A 53-year-old woman was admitted on 13th October 1988 with symptoms of dry cough and shortness of breath persisting for 1 year. On physical examination, fine crackles were audible over her back. Chest X-ray showed bilateral reticulonodular shadows and collapse of the bilateral lower lobes. Chest CT showed patchy areas of increased density distributed predominantly in the subpleural zone. Laboratory data on admission showed thrombocytopenia, hypergammopathy (IgG, 2044 mg/dl; IgA, 286 mg/dl; IgM, 1645 mg/dl), and positive ANF. Further examinations demonstrated that anti-platelet and anti-centromere antibodies were positive in the serum, and the titer of PA-IgG was high (56 ng/10(7) platelets). Histopathological examination of the open lung biopsy demonstrated honeycombing and thickening of the alveolar walls, with slight infiltration of chronic inflammatory cells. These histopathological findings were comparable with usual interstitial pneumonia. We report a very rare case of chronic interstitial pneumonia complicated by benign monoclonal gammopathy and thrombocytopenia. Although it remains unclear, these abnormalities may have been caused by immunological mechanisms.

A case of Trichosporon pullulans infection of the lung with adult T-cell leukemia

Fungal infections are often reported, but Trichosporon infection is very rare. A 78-year-old man with adult T-cell leukemia complicated with pulmonary infections is presented. Bronchial exudate culture revealed many yeast-like colonies, which were morphologically and biochemically identified as Trichosporon pullulans.

Endobronchial changes in chronic pulmonary venous hypertension

The bronchial venous system closely communicates with the pulmonary circulation. To assess the changes in the bronchial circulation in chronic pulmonary venous hypertension, fiberoptic bronchoscopy and right heart catheterization were performed in 31 patients with mitral stenosis. Nonpulsatile submucosal vessel dilatation, consistently seen in all patients and called the vessel dilatation score, was assessed visually by three independent bronchoscopists. The vessel dilatation score was correlated more closely with pulmonary artery wedge pressure (r = 0.687) (p less than 0.001) than to mean pulmonary artery pressure (r = 0.531) (p less than 0.01) and right atrial pressure (r = 0.178) (NS). The vessel dilatation score decreased after reduction of the left atrial load by surgery. These results suggest that the dilated vessels observed in patients with mitral stenosis are bronchial veins that are engorged secondary to increased blood flow via bronchopulmonary anastomoses.

Changes in phospholipids in bronchoalveolar lavage fluid of patients with interstitial lung diseases

We analyzed phospholipids of human bronchoalveolar lavage (BAL) fluids from patients with interstitial lung diseases; idiopathic pulmonary fibrosis (IPF), sarcoidosis, and eosinophilic granuloma (EG) and compared them to those of normal subjects. The content of phospholipid/ml of BAL fluid was significantly decreased in IPF. There was a significant decrease in phosphatidylglycerol (PG) and an increase in phosphatidylinositol (PI) in IPF but not in sarcoidosis and EG. Thus, the PG to PI ratio was significantly decreased in IPF. The dipalmitoyl species of phosphatidylcholine (PC) was found to be significantly decreased in IPF and sarcoidosis by molecular species analysis using high performance liquid chromatography. In contrast, the unsaturated species were increased in these diseases. The decrease in dipalmitoyl PC appeared to be a common feature in interstitial lung diseases. The changes in phospholipids in BAL fluids, especially decreases in DPPC and PG to PI ratio in IPF, appear to indicate that damage of alveolar Type II cells and/or of metabolic disturbance in pulmonary surfactant occurs in IPF.