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.

A Team-Based Early Action Protocol to Address Ethical Concerns in the Intensive Care Unit.

BACKGROUND: Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety. OBJECTIVE: To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families. METHODS: In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables. RESULTS: The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change. CONCLUSIONS: When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

Effects of the Use of the Provider Resilience Mobile Application in Reducing Compassion Fatigue in Oncology Nursing.

BACKGROUND: Oncology nurses have increased exposure to the prolonged illness, tragedy, loss, and premature death of patients. As a result, they are at higher risk for developing compassion fatigue. OBJECTIVES: The aim of this study was to examine if use of the Provider Resilience mobile application (PRMA) will improve oncology nurses' professional quality of life. METHODS: The quasiexperimental design was comprised of a longitudinal approach to evaluate the effect of an intervention program, PRMA, on professional quality of life between two nonrandomized groups (intervention and control) using pre- and post-tests in a sample of oncology RNs. FINDINGS: The findings of this study demonstrated no significant relationships between the intervention and control groups on secondary traumatic stress, compassion satisfaction, and burnout among oncology nurses.

Nursing Care of Patients Undergoing Chemotherapy Desensitization: Part II.

Chemotherapy desensitization protocols are safe, but labor-intensive, processes that allow patients with cancer to receive medications even if they initially experienced severe hypersensitivity reactions. Part I of this column discussed the pathophysiology of hypersensitivity reactions and described the development of desensitization protocols in oncology settings. Part II incorporates the experiences of an academic medical center and provides a practical guide for the nursing care of patients undergoing chemotherapy desensitization.
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Nursing Care of Patients Undergoing Chemotherapy Desensitization: Part I.

Hypersensitivity reactions to chemotherapeutic agents can cause the discontinuation of first-line therapies. Chemotherapy desensitization is a safe, but labor-intensive, process to administer these important medications. A desensitization protocol can enable a patient to receive the entire target dose of a medication, even if the patient has a history of severe infusion reactions. In this article, the authors explain the pathophysiology of hypersensitivity reactions and describe the recent development of desensitization protocols in oncology. In part II of this article, which will appear in the April 2016 issue of the Clinical Journal of Oncology Nursing, the authors will give a detailed account of how a desensitization protocol is performed at an academic medical center.
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A culture of avoidance: voices from inside ethically difficult clinical situations.

BACKGROUND: Healthcare providers experience many ethical challenges while caring for and making treatment decisions with patients and their families. OBJECTIVES: The purpose of this ethnographic study was to examine the challenges and circumstances that surround ethically difficult situations in oncology practice. METHODS: The authors conducted six focus groups with 30 oncology nurses in the United States and interviewed 12 key informants, such as clinical ethicists, oncologists, and nurse administrators. FINDINGS: The authors found that many healthcare providers remain silent about ethical concerns until a precipitating crisis occurs and ethical questions can no longer be avoided. Patients, families, nurses, and physicians tended to delay or defer conversations about prognosis and end-of-life treatment options. Individual, interactional, and system-level factors perpetuated the culture of avoidance. These included the intellectual and emotional toll of addressing ethics, differences in moral perspectives, fear of harming relationships, lack of continuity in care, emphasis on efficiency, and lack of shared decision making. This information is critical for any proactive and system-level effort aimed at mitigating ethical conflicts and their frequent companions-moral distress and burnout.

The nature of ethical conflicts and the meaning of moral community in oncology practice.

PURPOSE/OBJECTIVES: To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated. RESEARCH APPROACH: Ethnography. SETTING: Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota. PARTICIPANTS: 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists. METHODOLOGIC APPROACH: 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes. FINDINGS: Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources. CONCLUSIONS: Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter. INTERPRETATION: Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.

Making the call: a proactive ethics framework.

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly--often with lingering effects such as healthcare providers' disengagement and moral distress (McAndrew et al. Journal of Trauma Nursing 18(4):221-230, 2011), compromised inter-professional relationships (Rosenstein and O'Daniel American Journal of Nursing, 105(1):54-64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1-11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486-490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results.

Nurses' responses to ethical challenges in oncology practice: an ethnographic study.

Oncology nurses encounter increasingly complex ethical challenges in clinical practice. This ethnographic study explored 30 oncology nurses' descriptions of ethical situations and 12 key informants' perspectives on factors that influence the development of ethically difficult situations. Nurses described the goals of preventing patient suffering and injury, being honest with patients, and contributing meaningfully to patient improvement and stated goals. Nurses experienced six primary challenges in meeting their goals: being the eyes and arms of patient suffering, experiencing the precariousness of competing obligations, navigating the intricacies of hope and honesty, managing the urgency caused by waiting, straining to find time, and weighing risks of speaking up in hierarchal structures. Nurse actions included addressing concerns, creating other avenues, murmuring to one another, staying silent, and looking away. Several factors influenced nurses' responses to ethical challenges. Results imply a contextual model of moral action that reveals a need for altering practice environments in addition to improving nurses' ethics skills. Nurses are very aware of their moral responsibilities in ethically difficult situations and need work environments conducive to interprofessional collaboration and open dialogue.

Patient communication and strategies for managing fatigue.

Fatigue is common in patients with cancer. Fatigue is very distressing to patients, who often view it as an indication that their disease is progressing or that treatment is ineffective. Patients with a cancer diagnosis frequently have psychological distress. Communication and information help patients cope with the diagnosis of cancer and with the management of side effects. Presenting clear, concise, and well-timed communication to patients regarding fatigue management is an important role for health care providers. This article gives an overview of cancer-related fatigue, the various attitudes that prevail among cancer patients seeking information, and interventions patients can use to help manage their fatigue. Armed with this knowledge, oncology nurses and physicians can better meet the need to provide appropriate information about fatigue to patients and families, and at most appropriate points in the illness.