Clinical Nurse Specialists Guide Staff Nurses to Promote Practice Accountability Through Peer Review.

PURPOSE: The aim of the study was to describe the clinical nurse specialist role in developing and implementing a staff nurse education program to promote practice accountability using peer review principles. BACKGROUND: Peer review is essential for professional nursing practice demanding a significant culture change. Clinical nurse specialists in a Magnet-designated community hospital were charged with developing a staff nurse peer review education program. RATIONALE: Peer review is a recognized mechanism of professional self-regulation to ensure delivery of quality care. The American Nurses Association strongly urges incorporating peer review in professional nursing practice models. Clinical nurse specialists play a critical role in educating staff nurses about practice accountability. DESCRIPTION: Clinical nurse specialists developed an education program guided by the American Nurses Association's principles of peer review. A baseline needs assessment identified potential barriers and learning needs. Content incorporated tools and strategies to build communication skills, collaboration, practice change, and peer accountability. OUTCOME: The education program resulted in increased staff nurse knowledge about peer review and application of peer review principles in practice. CONCLUSION: Clinical nurse specialists played a critical role in helping staff nurses understand peer review and its application to practice. IMPLICATIONS: The clinical nurse specialist role will continue to be important in sustaining the application of peer review principles in practice.

Nursing priorities, actions, and regrets for ethical situations in clinical practice.

PURPOSE: Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify priorities, action responses, and regrets. METHODS: Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, nurse actions, and situational outcomes. Data on nursing priorities and actions were analyzed and categorized using a constant comparison technique. FINDINGS: Addressing patient autonomy and quality of life were ethical priorities in the majority of cases. In many cases, nurses analyzed ethics from a diffuse perspective and only considered one dimension of the ethics conflict. However, some nurses were specific in their ethical analysis and proactive in their action choices. Nurses also identified 12 ethics-specific nurse activities, five ways of being, three ways of knowing, and two ways of deliberating. In 21 cases, nurses chose not to pursue their concerns beyond providing standard care. Several nurses expressed significant regret in their narration; most regretted unnecessary pain and suffering, and some claimed they did not do enough for the patient. CONCLUSIONS: Not enough specific, evidence-based ethics actions have been developed. Stronger and more proactive nursing voices with early ethics interventions would make valuable contributions to quality of care for patients, especially at the end of life. CLINICAL RELEVANCE: Ever-expanding treatment options raise ethical issues and challenge nurses to be effective patient advocates. Evidence-based nursing interventions that promptly identify and address moral conflict will benefit patients, their families, and the entire healthcare team by mitigating potential moral distress and disengagement.

Early indicators and risk factors for ethical issues in clinical practice.

PURPOSE: Nurses in all clinical settings encounter ethical issues that frequently lead to moral distress. This critical incident study explored nurses' descriptions of ethically difficult situations to identify risk factors and early indicators of ethical conflicts. METHODS: Employing the critical incident technique, researchers developed a questionnaire that collected information on ethically difficult situations, their risk factors and early indicators, nurse actions, and situational outcomes. Two nurse researchers independently analyzed and categorized data using a constant comparison technique. FINDINGS: Most of the ethically difficult situations pertained to end-of-life care for children and adults. Conflicts in interpersonal relationships were prevalent. Nurses were especially moved by patient and family suffering and concerned about patient vulnerability, harm-benefit ratio, and patient autonomy. Researchers discovered risk factor categories for patients, families, healthcare providers, and health systems. Additionally, researchers found subcategories in six major categories of early indicators: signs of conflict, patient suffering, nurse distress, ethics violation, unrealistic expectations, and poor communication. CONCLUSIONS: Nurses are keenly aware of pertinent risk factors and early indicators of unfolding ethical conflicts. Many nurses reported feeling powerless in the face of ethical conflict. Research that develops interventions to strengthen nurses' voices in ethically difficult situation is warranted. CLINICAL RELEVANCE: Nurses are in a key position to identify patient situations with a high risk for ethical conflict. Initiating early ethics consultation and interventions can alter the course of pending conflicts and diminish the potential for patient and family suffering and nurses' moral distress.