The use of life review to enhance quality of life of people living with AIDS: a feasibility study

People living with AIDS (PLWA) are confronted with uncertainty and their own mortality at an earlier than expected age. Life review, an intervention that has the potential to increase life satisfaction in the elderly experiencing transition points in their lives, may have a similar effect when used with PLWA. Therefore, the purpose of this feasibility study was to explore the use of life review in a sample of 20 PLWA through a randomized controlled trial of its effectiveness in decreasing depressive symptoms and in increasing self esteem, quality of life, and purpose in life. Compared to the control group, the treatment group had an improved overall quality of life and self-esteem over 12 months, less depressive symptoms over 12 months, and a greater purpose in life at 3 months. The effects that were seen were mainly small to medium effects. The findings from this feasibility study suggest the potential value of life review to enhance quality of life, purpose in life, and self-esteem, and to decrease depressive symptoms in PLWA. Further research is needed with a larger sample and with other groups such as PLWA experiencing virologic failure.

Transcending the suffering of AIDS

The overall purpose of this qualitative study was to describe how patients with AIDS (PWAs) transcend the emotional and physical suffering of their illness. Content analysis of the interviews of 5 PWAs resulted in 3 main themes: creating a meaningful life pattern, connectedness, and self-care. The results of this study provide presumptive evidence that PWAs can transcend the suffering associated with a life-threatening illness and live meaningful and productive lives. Nurses who anticipate actual and potential growth in PWAs will be able to validate such experiences and feelings and encourage further development.

The nursing shortage, patient care, and ethics

Although nursing shortages are not new, many nurses consider the present shortage to be different from those in the past. Nurses are again questioning whether patients are receiving the quality of care they deserve. Overwhelmed by this nursing shortage, nurses are trying to reconcile how to fulfill their duties to advocate for good patient care and to warn patients about conditions that are possibly detrimental to their welfare. This article discusses two ethical issues that nurses, in the midst of a nursing shortage, face in their clinical practice: lack of control over their practice and potential for harm to patients and themselves. There is also a description of strategies that nurses can use to promote and maintain an environment within the organization that supports providing good patient care.

Medication errors: ethical implications

Errors in health care are receiving much attention today, although committing such errors is not a new phenomenon. Nurses are taught procedures so that they are less likely to make mistakes. Yet nurses do make errors. Although many types of errors can and do occur in the health care setting, this article focuses on a discussion of medication errors and related ethical implications. Several ethical issues may arise as a result of medication errors: harm to patients, whether to disclose the error, erosion of trust, and impact on quality care. Nurses' appropriate ethical responses to medication errors need to be supported. Changing the health care system will help nurses to promote patient welfare, lessen the chance of harm, and reduce the likelihood of medication errors occurring.

Moral distress: a pervasive problem

The shortage of nurses and the flaws within the structure of the current health care system are compromising the nurse's ability to provide competent, compassionate care. Nurses are increasingly disturbed because they see themselves as ineffective advocates for their patients. Nurses, unable to take the appropriate ethical actions, feel paralyzed by their situation. The author's recent conversations with staff nurses about their clinical practice suggest that moral distress has become a very pervasive problem. The purpose of this article is to describe ethical practice, moral distress, the imbalance of power, and the nature of an ethical environment. There is a discussion of potential strategies that will help to create and maintain an ethical environment thereby reducing moral distress such as facilitating dialogue, developing a support system, providing opportunities for professional development, and developing and revising institutional policies.

Adherence in chronic disease

Nonadherence to treatment regimen is a prevalent problem of patients with chronic disorders. Approximately half of the patients with a chronic disease have problems following their prescribed regimen to the extent that they are unable to obtain optimum clinical benefit. This chapter reviews the state of knowledge regarding adherence to chronic disease regimens across the life span and demonstrates that the extent and nature of the adherence problems are similar across diseases, across regimens, and across age groups. Adherence to the commonly prescribed regimens is addressed, including pharmacological therapies, therapeutic diets, and therapeutic exercise. Randomized, controlled studies focusing on various educational, behavioral, cognitive, and affective interventions to improve adherence are included. Based on this review, further work is needed to better understand and improve adherence. New strategies for analysis and measurement will support these needed advances in the field of adherence.

Problem drinking and medication adherence among persons with HIV infection

OBJECTIVE

To examine the relation between problem drinking and medication adherence among persons with HIV infection.

DESIGN

Cross-sectional survey.

SETTING/PARTICIPANTS

Two hundred twelve persons with HIV infection who visited 2 outpatient clinics between December 1997 and February 1998.

MEASUREMENTS AND MAIN RESULTS

Nineteen percent of subjects reported problem drinking during the previous month, 14% missed at least 1 dose of medication within the previous 24 hours, and 30% did not take their medications as scheduled during the previous week. Problem drinkers were slightly more likely to report a missed dose (17% vs 12 %, P =.38) and significantly more likely to report taking medicines off schedule (45% vs 26%, P =.02). Among drinking subtypes, taking medications off schedule was significantly associated with both heavy drinking (high quantity/frequency) (adjusted odds ratio [OR], 4.70; 95% confidence interval [95% CI], 1.49 to 14.84; P <.05) and hazardous drinking (adjusted OR, 2.64; 95% CI, 1.07 to 6.53; P <.05). Problem drinkers were more likely to report missing medications because of forgetting (48% vs 35%, P =.10), running out of medications (15% vs 8%, P =.16), and consuming alcohol or drugs (26 % vs 3 %, P <.001).

CONCLUSION

Problem drinking is associated with decreased medication adherence, particularly with taking medications off schedule during the previous week. Clinicians should assess for alcohol problems, link alcohol use severity to potential adherence problems, and monitor outcomes in both alcohol consumption and medication adherence.

When the family asks, 'what happened?'

Because of the high level of acuity of hospitalized patients, untoward events can and do occur. Very often, nurses develop a caring relationship with the families of these patients. As a result, the family may approach the nurse about this negative turn of events. The questions that the family raises may create an ethical dilemma for the nurse. The nurse may wonder how to respond, feel powerless and "caught in the middle," and experience moral distress because of constraints in the health care system. This article discusses the ethical perspective of caring and the "nurse in the middle" phenomenon. Several strategies to help nurses manage this issue include consulting with a mentor, consulting with the institutional ethics committee, and promoting an ethical climate within the health care setting.

'Conflicts of interest': an ethical dilemma for the nurse researcher

More nurse researchers are turning to industry as a possible source of funding to support their scientific work. Corporations may be very interested in particular projects because of the fit that exists between the investigator's interest and the company's product. However, researchers need to be cautious since accepting funding from and entering into a financial relationship with industry may lead to "conflicts of interest." The purpose of this article is to discuss the ethical issues when there are conflicts of interest. The author presents recommendations designed to help nurse researchers avoid and address this potential ethical problem.

Psychometric properties of the Index of Homophobia Scale in registered nurses

The psychometric properties of the Index of Homophobia Scale (IHS; Bouton et al., 1987) were examined in a sample of registered nurses (n = 95). Scores on the IHS may range from 0 (no homophobia) to 28 (highly homophobic). This sample had relatively low total scores on the IHS (M = 7.99, SD = 5.41), indicating that subjects were predominantly not homophobic. Internal consistency as estimated by Cronbach's alpha was .88. The average item mean was 1.14 (SD = 0.29) ranging from .77 to 1.48. Corrected item-to-total scale correlations were satisfactory, ranging from .58 to .75. Inter-item correlations ranged from .35 to .67 indicating some redundancy in content sampling. The 7-item IHS indicates promise for future use with registered nurses, and perhaps also with other health care professionals in adequately and accurately measuring homophobia.

Clinical research: what do patients understand?

An increasing amount of clinical research is being conducted to test the efficacy and effectiveness of new medications, therapies, and medical procedures. These studies often require that patients be invited to be subjects. However, what do patients really understand whenever they are asked to participate in clinical research? Are patients aware that research is clearly different from treatment? Are they aware that their participation in research is to benefit future patients? Despite the desire of clinical agencies to support research, there is the concern about how they can best protect the rights of patients who are subjects in this research. The author briefly discusses clinical research, patients as vulnerable subjects, the therapeutic misconception, and informed consent. In addition, recommendations are provided to help assure that the rights of patients who are research subjects are protected.

What does it mean to blow the whistle?

Whistle blowing causes people to pay attention. An alarm has been sounded drawing attention to a particular set of circumstances. When nurses blow the whistle because of unethical or incompetent colleagues, they are going public with this information. Yet, even though nurses are able to provide an ethical justification for the action, not all will look favorably on what has been done. This article examines the concept of whistle blowing, its relationship to advocacy, and some consequences of whistle blowing. This article provides recommendations for educators, health care agencies, and nurses as ways to support nurses who choose to blow the whistle.

The patient no one liked

Despite professional admonitions to treat patients with dignity and to promote their well being, there are some patients who are unpopular with or not liked by nurses. Caring for these patients presents an ethical challenge for nurses. The purposes of this article are to explore the issue of bias and the use of labels, as well as the subsequent ethical concerns of respecting the uniqueness of the patient and preventing harm when nurses have a negative bias toward and label particular patients. The authors discuss several implications for nursing practice, including engaging in introspection, understanding the "problem" patient, actively involving patients in their care, and evaluating strategies used to eliminate negative bias and labeling.

Adherence to combination therapy in persons living with HIV: balancing the hardships and the blessings

Evidence from clinical trials demonstrates the benefits of combination therapy in persons living with HIV (PLWHIV); however, there is little information about the patient's experience when taking a complex regimen. Thus, the primary purpose of this preliminary study was to describe the everyday experience of PLWHIV who were prescribed combination therapy in order to identify a potential intervention to enhance adherence to this regimen. The secondary purpose was to examine the association between adherence to combination therapy and quality of life. The researchers purposively sampled six PLWHIV (two women and four men) to reflect the diverse demographic characteristics of the population of PLWHIV. The themes that evolved were decision making, difficulties, problem solving, and quality of life. Clinical indicators provide only one measure of the effectiveness of combination therapy. When the informants described the outcome of this therapy as "having their life back," they spoke of having quality in their lives that they viewed as more than their physical health.

Incentives in research: ethical issues

The participation of some subjects in research may be association with their receiving some compensation for their time and effort. Is the use of monetary or other nonmonetary incentives ethical? Do incentives make a study so enticing that it is difficult to resist being a participant? The authors discuss some relevant ethical questions that a researcher needs to address when providing stipends to study subjects. Additionally, there is a discussion of implications for nurses such as acquiring knowledge of research and ethics, creating an environment in which the patient's questions and any issues can be discussed, advocating for the patient who is being asked to participate, and the nurse's responsibilities when asked to help with recruitment efforts.

Culture, ethics, and respect: the bottom line is understanding

As the world becomes smaller, there is increasing recognition that the world is more culturally diverse. People within a particular group share customs, habits, and values; however, these individuals may share few, if any, beliefs and practices with people from other cultural groups. This increasing cultural diversity raises questions about ways to deliver appropriate and respectful health care to patients from other cultures. This article discusses culture, culture and health care, and respect for culture. There is a description of means that nurses can use to provide culturally relevant care. Ethical practice requires a recognition of one's biases, a sensitivity to cultural differences, the avoidance of generalizations about cultures, and the provision of culturally relevant care.

Treatment decision making: who should decide?

Why is someone other than a competent adult patient considered to be the person to make important treatment decisions? Since one's values influence decision making, who other than the patient should make these significant decisions? The author argues that competent adult patients should make treatment decisions because of the moral nature of these decisions. Recommendations for facilitating the patient's active involvement include increasing one's understanding of values, autonomy, and decision making; identifying personal values; creating a supportive environment; educating patients about their role in decision making; and advocating for patient involvement in treatment decisions.

Multicultural issues and ethical concerns in the delivery of nursing care interventions

Nurses are beginning to recognize the importance of understanding the values, beliefs, and health practices of different cultures in order to provide care that is appropriate and culturally relevant to diverse patient populations. Individuals from other cultures may have different languages and customs. These cultural factors are important to the nurse's understanding of the specifics of health care practice. Culture and ethnicity may influence one's physical development and exposure to health compromising environments and conditions. This article uses a case study to describe a process that health care providers can use when faced with ethical dilemmas that arise when caring for patients from different cultures. Nursing strategies to promote culturally sensitive care are discussed, and include cultural assessment, heightening sensitivity to ethical issues in cultural diversity, and the role of continuing education in providing culturally competent care.

Do nurses avoid AIDS patients? Avoidance behaviours and the quality of care of hospitalized AIDS patients

To examine whether AIDS patients are stigmatized by nurses providing their care a study was conducted with 100 matched AIDS and general medical (GM) patients in two university and two community hospitals. Quality of care and avoidance behaviours were measured by direct, systematic observation during a concurrent 12-hour period. Stigmatizing attitudes of nurses were measured using standardized instruments of homophobia, fear of AIDS and attitudes toward illicit drug use. Nurses made more eye contact and touched AIDS patients more frequently then GM patients, however these differences did not reach the level of statistical significance They spent significantly more time with AIDS patients (W = 3134.0, p = 0.012). Whether or not nurses were fearful of HIV infection, were homophobic or held negative feelings about drug use made no difference in the level of care provided to AIDS patients, but did for GM patients. However, avoidance behaviours were associated with lower quality of care across all patients regardless of diagnosis. Hierarchical regression models demonstrated that increased time spent with patients and higher percentage positive of verbal mannerisms were associated with an increase in the quality of patient care. Provision of physical care showed the least amount of variation between patients in general. It was concluded that nurses' attitudes had no impact on whether or not AIDS patients were shunned by nurses. The provision of psychosocial care showed the greatest variation and seemed more sensitive to individual nurses' attitudes. The quality of care received by the overwhelming majority of patients could only be termed adequate. Nurses exhibited the greatest caution when performing procedures with patients whose HIV status was unknown. The AIDS population studied were mostly well-educated, homosexual men. Whether these results would be replicated with a different population of patients is as yet unknown.

The inadvertent breach of confidentiality

Patients believe that personal information that they share with their health care providers will be kept strictly confidential. Safeguarding a confidence has been and continues to be an expected professional behavior. Yet, a common ethical problem that nurses face in their everyday practice is the inadvertent disclosure of private information about particular patients to individuals who have no need for this information. This article discusses the inadvertent breach of confidentiality and its related ethical concepts: privacy, respect for persons, trust and fidelity, and the potential for harm or injury. Recommendations are provided to enable nurses to avoid and manage situations that involve an inadvertent breach of confidentiality.

Health-related quality of life in chronic disorders: a comparison across studies using the MOS SF-36

The purpose of this report is to examine health-related quality of life (HRQoL) as measured by the Medical Outcomes Study Short Form-36, across patient populations with chronic disorders and to compare quality of life (QoL) in these subjects with normative data on healthy persons. Six studies, within the Center for Research in Chronic Disorders at the University of Pittsburgh School of Nursing, in patients with urinary incontinence, prostate cancer, chronic obstructive pulmonary disease (COPD), acquired immune deficiency syndrome (AIDS), fibromyalgia and hyperlipidaemia provided the data for analysis. The results demonstrated that not only did the prostate cancer and hyperlipidaemia patients have the highest QoL across the chronic disorders, but their QoL was comparable to normative data on healthy persons. Homebound, elderly, incontinent patients had the lowest QoL for physical functioning, whereas patients hospitalized with AIDS had the lowest QoL in general health and social functioning. Patients with COPD had the lowest QoL in role-physical, role-emotional and mental health. Patients with fibromyalgia had the lowest QoL in bodily pain and vitality. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia generally had lower QoL. Prostate cancer and hyperlipidaemia patients had QoL comparable to normative data. Compared to normative data, patients with urinary incontinence, COPD, AIDS and fibromyalgia had more variability for role-emotional. AIDS patients had more variability on physical functioning, bodily pain and social functioning compared to the normative data. These data suggest that patients with various chronic disorders may have QoL that is lower in most domains compared to a healthy population. However, there may be differences in the domains affected as well as the extent of variation across specific chronic disorders.

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.

Everyday ethics

While dramatic issues such as assisted suicide and genetic engineering raise unique ethical questions for health care professionals, they are not the typical ethical concerns that nurses face in their daily practice. The more usual ethical situation or "everyday ethics" occur during the regular interactions that nurses have with patients, their families, and other health care providers. Everyday ethics is central to nursing practice. Being attuned to this aspect of professional practice gives meaning and purpose to nursing care. Typical clinical examples provide the backdrop for the discussion of everyday ethics. Through increasing their knowledge of ethical theory and values, their sensitivity to ethical issues in daily practice, their ability to use critical thinking, and their communication skills, nurses will be better able to provide ethically appropriate care to their patients.

Multiple authorship: issues and recommendations

The increase in multidisciplinary research has led to a subsequent expansion of multiple authored articles in nursing as well as other disciplines. Although there are benefits to multiple authorship, there also are areas of possible conflict. The lack of adequate guidelines to address issues that may arise from multiple authorship heightens the possibility of disputes. Developing a blueprint for the preparation and presentation of papers emanating from a research team's work early in the project can avoid conflicts and ensure that the efforts of the appropriate individuals are reflected in the publications. This article discusses several issues related to authorship, including the assignment of authorship credit, the increased pressures to publish, and the complexity of authorship issues associated with multisite studies. The authors offer recommendations to reduce problems that may arise among members of a research team because of authorship issues. In addition, they include the guidelines that their multidisciplinary research team developed early in their project.

HIV, self-transcendence, and quality of life

Self-transcendence is a developmental characteristic that expands one's boundaries of the self to take on broader life perspectives, activities, and purposes that help one discover or make meaning of one's life. However, no quantitative studies were found in the research literature that focused on self-transcendence or on the relationship between self-transcendence and quality of life in people infected with HIV. To examine these variables in this population, 46 HIV-positive subjects completed Reed's Self-Transcendence Scale and Ferrans and Powers' Quality of Life Index. The results demonstrated that overall self-transcendence for this sample was relatively high; quality of life was higher than that reported in previous research; and there were some significant group differences among the three HIV clinical categories.

Ethical questions inherent in compliance

Promoting patient compliance is considered to be good clinical practice. However, compliance conveys a sense of being submissive or obedient to another; therefore, promoting compliance becomes a paternalistic action. The author uses a clinical situation to demonstrate some of the ethical questions related to compliance (i.e., who decides, who knows best, and how noncompliant patients are treated) and discusses these questions using the ethical precepts of doing no harm and respecting autonomy.

Quality of life, ethical decisions, and the patient's story

Advances in health care technology have the potential to increase longevity and relieve suffering. However, not all people will benefit; the quality of their lives may not be better. Consequently, use of this advanced technology creates ethical situations for health care providers and their patients. Quality of life becomes a key factor to consider; yet, this is an illusive idea. Since quality of life is subjective, multidimensional, and contextual, there is a need to hear the patient's story. What is important to the individual patient and produces the most satisfaction for the patient should become the primary criteria to consider when these ethical situations arise.

Issues at the end of life

A recent study by David Asch reported in the New England Journal of Medicine has intensified discussions about euthanasia and assisted suicide. That investigation has prompted nurses and other health care providers to raise questions about what is appropriate care for dying patients. To that end, this article provides an overview of relevant issues for nurses to consider when patients are at the end of life: quality of life, suffering, pain management, double effect, respect for autonomy, and trust and nonabandonment. Understanding these issues and enhancing communication between and among all relevant individuals when treatment decisions are being made will enable nurses to provide appropriate patient care at the end of life.

Ethical issues and the new staff mix

The role of the professional nurse is changing due to the effects of work redesign programs, downsizing, and the increasing use of unlicensed assistive personnel (UAP). Nurses recognize that they cannot provide all aspects of the patient's care; however, nurses generally lack the knowledge and skill to delegate effectively. If nurses cannot delegate appropriate tasks to others, mistrust those to whom they are delegating tasks, and show limited respect toward UAP when delegating and supervising their work, there is the distinct possibility that patients will not receive quality care. The authors examine the ethical issues of respect for persons, trust, and promoting patient well-being, as well as the nursing issues related to accountability and responsibility when delegating care. There are several recommendations provided to enable nurses to reduce the threat of compromised patient care created by this new staff mix.

Fear of AIDS, homophobia, and occupational risk for HIV. A staff development challenge

Nursing is committed to providing quality care; however, nursing practice has been challenged by patients with AIDS. In this pilot study, the authors investigated the relation among nurses' homophobia, fear AIDS, and occupational risk for contracting HIV. With their findings, they found that a positive attitude toward homosexuality, more clinical experience, and more experience with HIV patients contribute to a positive attitude toward AIDS. The authors recommend that staff development programs focus on the affective domain of nursing, universal precautions and infection control, and precepted experiences for new graduates.

Managed care and the nurse's ethical obligations to patients

The goal of managed care is to control health care costs by such means as keeping people healthy and decreasing the length of hospital stays. This change in health care delivery has resulted in work redesign programs, lay-offs, cross-training, and the use of an increasing number of nonprofessional care providers. The challenge for nursing, as a result of these changes, is how to fulfill its obligations of fidelity and due care. The authors discuss these ethical responsibilities and the impact that managed care is having on the fiduciary relationship between nurse and patient. Four strategies that nurses can use to fulfill their obligations include engaging in personal reflection, communicating and collaborating, protecting patient's rights, and evaluating patient outcomes.

When the patient lacks decision-making capacity

Our society supports the right of its members to be self-determining and to make decisions based on their personal values and beliefs. However, what happens when a person lacks the capacity to make decisions? The author identifies criteria for determining decision-making capacity and discusses the surrogate decision maker, the best interests standard, and the substituted judgment standard. Nursing implications focusing on treating the patient with dignity and respect and protecting the patient's rights are discussed.

Should the nurse participate in planned deception?

Nurses encounter situations in their practice involving planned deception. A decision has been made that the deception will enhance the patient's welfare. For the deception to work, all who care for the patient must participate. To determine if planned deception is ethical, there is a need to consider ethical concerns related to promoting patient well-being, deception, respect for persons, and truthtelling. Before deciding what they ought to do nurses need to examine the various alternatives that are available.

Technology's seductive power

Advances in technology suggest new possibilities in health care and have become equated with state-of-the-art health care. The promise of technology has the potential to act as a seductive force luring nurses and other health care providers to use it and luring patients to request it. If nurses become so enchanted with technology, the patient as a person may be overlooked. By focusing on caring and the patient's experience of being ill, nurses can avoid being seduced by and dependent upon the use of technology when providing patient care.

Informed consent: the consent component

Individuals who participate in treatment or research protocols should perceive that their decision is a free choice and that they are acting of their own accord. However, these persons may feel as if they are being pressured to participate in the protocol being described. The author discusses the two components of consent: voluntariness and authorization and offers suggestions to nurses to fulfill their moral responsibility to be patient advocates.

Informed consent: the information component

Patients are asked to give informed consent for both treatment and research protocols. Yet, is their consent really informed? This article focuses on the information component of informed consent. The author discusses informed consent as it relates to the ethical principle of respect for autonomy, presents nurses' perceptions of informed consent, and makes several recommendations that nurses can use to ensure that consent is informed.

Conflict of interest: its relationship to integrity in the academic setting

Conflict of interest is an issue not only for business leaders, government officials, and researchers, but also academicians. As an ethical issue, conflict of interest involves competing interests as well as raises questions related to an individual's integrity. A case is used to discuss these ethical issues in the academic setting. Recommendations are provided to prevent, reduce, or avoid these ethical tensions, with particular attention to the development of policies to support institutional and, thereby, personal and professional relationships among faculty and students.

Ethical dilemmas in the high-risk nursery: wilderness experiences

Ethical dilemmas in the high-risk nursery are similar to wilderness experiences. Reinforcers of these experiences for nurses include a lack of knowledge of ethics, communication failures, and the immediacy of the situation. Recommendations are presented to enable nurses to address these ethical dilemmas and to become more actively involved in the decision-making process.

Health care professionals' characterizations of the system of care for long-term ventilator-dependent patients: a preliminary study

The purpose of this study was to characterize, from multiple professional perspectives, current management approaches and systems of care for long-term ventilator-dependent patients. This study was preliminary in nature and served to generate questions to be explored with subsequent research. A focus group methodology was used. Three focus sessions were held, with participants representing nursing, social services, and respiratory therapy. Field notes were recorded by two independent observers. The primary themes arising from the narrative data were: (i) caregiver impact, (ii) system barriers to appropriate care, (iii) communication difficulties among professionals and between patients and professionals, (iv) ethical concerns, and (v) patient characteristics that influence medical management and patient outcomes. Implications include the need for systematic research regarding caregiver impact, ethical practice of health care professionals, and the epidemiology of ventilator dependency, as well as evaluative studies of different system approaches to caring for these patients.

The code for nurses: guidelines for ethical practice

Nurses regularly are faced with ethical situations in their practice. Despite potentially having had as part of their educational programs an ethics course or specific classes addressing ethical issues, many nurses still feel ill-equipped when ethical dilemmas occur. This article discusses the Code for Nurses as a resource that nurses can use for determining the appropriate action(s) when an ethical dilemma arises.

Respect for persons: the patient with AIDS

Even though the Code for Nurses calls for nurses to provide nondiscriminatory care and to treat patients with respect, research shows that nurses (1) are reluctant to provide care to and (2) believe that they should have the right to refuse to care for patients with AIDS. This article presents two contrasting situations and focuses on the ethical principle of respect for persons. Nurses need to examine their own practice to determine if they are providing care that respects the uniqueness and rights of their patients.

Empowering nurses through nursing ethics committees

Nurses are patient advocates who often feel powerless when implementing that role in ethical situations. One strategy to empower nurses in their advocacy role is the development and use of nursing ethics committees within health care institutions.

An ethical dilemma in the neonatal intensive care unit: providing due care

We have discussed the ethical principles of beneficence, nonmaleficence, fidelity, and justice as they relate to a case involving what to do when there are too many sick neonates in an NICU. The use of ethical principles clarified the issues surrounding the shift in power and the decision making. This clarification led to the various short-term and long-term strategies that were designed to resolve the ethical dilemma. In addition, analysis of this case demonstrates that issues related to justice frequently involve the making or the questioning of policy so that all can be treated in a fair way. Providing for individuals in a fair manner reduces the potential for harm. Focusing on ethical principles may serve to deemphasize and diffuse the control and territorial issues that may arise in similar cases. This refocusing will then enable all parties to address their common concern--how to provide due care to sick neonates and their families.

Factors influencing ethical decision making in the home setting

The process of ethical decision making does not differ according to the patient care setting. However, various factors in home care affect the way in which decisions are made. The factors to consider are the amount of time needed to make a decision, the involvement of the patient and family, the need for support systems, the difficulties with interdisciplinary communication, and the lack of an ethics committee. Recognizing the ways in which these variables affect the decision making can help home healthcare nurses resolve the ethical dilemmas they face. In addition, staff education programs, the use of consultants, and the development of ethics committees are possible strategies to facilitate ethical decision making.

Demystifying ethical decision making

Ethical dilemmas frequently occur in the practice of orthopaedic nursing. Nurses, however, are often unsure about how to resolve these dilemmas. The language of ethics remains elusive. Yet, because nurses have a central role in patient care, they need to become more comfortable making ethical decisions related to their practice. This article briefly describes the dialectical process of ethical decision making and demonstrates this process by using a case presentation. Readers are encouraged to put themselves into the role of the bedside nurse in the case, determine what they believe to be the right action, and provide a well-grounded rationale for that decision.

Stigma, AIDS and quality of nursing care: state of the science

Reports of fear and psychological distress on the part of nurses when caring for AIDS patients have drawn attention to the real possibility that care for this very sick group of patients may be less than adequate. This paper reviews what is currently known about the attitudes of nurses and the care provided to HIV-infected individuals. The authors reveal the paucity of empirical data concerning quality of care and how the concept of stigma might serve to aid our understanding. The need for more research documenting the quality of care provided to HIV-infected patients is discussed.