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1.
AJOB Empir Bioeth ; 11(4): 275-286, 2020.
Article in English | MEDLINE | ID: mdl-32940565

ABSTRACT

BACKGROUND: Evidence suggests that healthcare professionals feel inadequately equipped to manage ethical issues that arise, resulting in ethics-related stress. Clinical ethics consultation, and preventive ethics strategies, have been described as ways to decrease ethics-related stress, however information is limited regarding specific sources of ethical concern. METHODS: The purpose of this study was to conduct a retrospective, longitudinal analysis of a comprehensive database of ethics consultations, at a major academic medical center in the Northeast United States in order to: (1) Discern major sources of ethical concern, (2) Evaluate how these have changed over time in their content and frequency, (2a) Evaluate trends in nurse versus physician-initiated requests. RESULTS: Six major reasons for requesting an ethics consult were identified: Conflict Over Goals of Care, Decisional Capacity, Withholding/Withdrawing Treatment, Proxy Decision Making, Communication, and Behavior. Themes were operationally defined by the study team. An increase in requests related to Conflict Over Goals of Care (ß = 0.7, 95% CI = 0.2-1.2, p = 0.008) and Discharge Planning (ß = 2.2, 95% CI = 1.4-3.1, p < 0.001), and a trend toward increased number of consults for behavior-related consults from nurses (median 6.5% versus 2.3%, p = 0.07) were noted. Nurses were significantly more likely than physicians to request ethics consultation for Communication (yearly median 10.4% of cases vs 1.3% of cases, p = 0.01), whereas, physicians were significantly more likely to request ethics consultation for Proxy Decision-Making than nurses (yearly median 26.0% of cases vs 13.0%, p = 0.005) and for Decision-Making Capacity (yearly median 7.5% of cases vs 4.0%, p = 0.04). CONCLUSIONS: This study revealed several noteworthy and previously unidentified trends in consultation requests, and several important distinctions between the sources of ethical concern nurses identify versus those physicians identify. These findings can be used to develop future preventive-ethics frameworks.


Subject(s)
Academic Medical Centers/ethics , Ethics Consultation , Motivation , Nurses , Occupational Stress , Physicians , Databases, Factual , Ethics Committees, Clinical , Ethics Consultation/trends , Ethics, Medical , Ethics, Nursing , Humans , Longitudinal Studies , New England , Nurses/trends , Physicians/trends , Retrospective Studies
2.
Nurs Ethics ; 27(1): 28-39, 2020 Feb.
Article in English | MEDLINE | ID: mdl-31032701

ABSTRACT

BACKGROUND: The Clinical Ethics Residency for Nurses was offered selectively to nurses affiliated with two academic medical centers to increase confidence in ethical decision-making. RESEARCH QUESTION/AIM: To discover how effective the participants perceived the program and if their goals of participation had been met. RESEARCH DESIGN: A total of 65 end-of-course essays (from three cohorts) were analyzed using modified directed content analysis. In-depth and recursive readings of the essays by faculty were guided by six questions that had been posed to graduates. ETHICAL CONSIDERATIONS: Institutional review board approval was granted for the duration of the program and its reporting period. Confidentiality was maintained via the use of codes for all evaluations including the essays and potentially identifying content redacted. FINDINGS: An umbrella theme emerged: participants had developed ethical knowledge and skills that provided a "moral compass to navigate the many gray areas of decision-making that confront them in daily practice." Six major themes corresponding to questions posed to the participants included the ability to advocate for good patient care; to support and empower colleagues, patients, and families; they experienced personal and professional transformation; they valued the multimodal nature of the program; and were using their new knowledge and skills in practice. However, they also recognized that their development as moral agents was an ongoing process. DISCUSSION: Findings support that enhancing nurse confidence in their moral agency with a multimodal educational approach that includes mentored practice in ethical decision-making, enhancing communication skills and role-play can mitigate moral distress. A majority found the program personally and professionally transformative. However, they recognized that ongoing ethics discussion involvement and supportive environments would be important in their continued development of ethical agency. CONCLUSION: Multimodal ethics education programs have potential to be transformative and enhance nurse confidence in their ethical decision-making.


Subject(s)
Ethics, Clinical/education , Nurses/psychology , Prisons/standards , Stress Disorders, Post-Traumatic/psychology , Adult , Analysis of Variance , Cross-Sectional Studies , Educational Measurement/methods , Female , Humans , Italy , Male , Middle Aged , Nurses/trends , Prisons/trends , Qualitative Research , Stress Disorders, Post-Traumatic/complications , Surveys and Questionnaires
3.
Hastings Cent Rep ; 48(5): 7-9, 2018 Sep.
Article in English | MEDLINE | ID: mdl-30311206

ABSTRACT

The debate about health insurance coverage and the related issue of unequal access to health care turn on fundamental questions of justice, but for an individual patient like DM, the abstract question about who is deserving of health insurance becomes a very concrete problem that has a profound impact on care and livelihood. DM's circumstances left him stuck in the hospital. A satisfactory discharge plan remained elusive; his insurance coverage severely limited the number and type of facilities that would accept him; and his inadequate engagement in his own rehabilitation process limited discharge options even further. Despite extensive involvement with the psychiatry, social work, physical therapy, and occupational therapy teams, DM consistently made "bad" decisions. He repeatedly refused antibiotics and did not consistently work with rehab services to improve his strength and mobility. Although the clinicians wanted to provide him with the best care possible, he often seemed unwilling to do the things necessary to achieve this care-or perhaps his depression rendered him unable to do so. He also tended to take out his frustration on staff members caring for him. All of this was, in turn, very frustrating for the staff. It may be easy, however, to make too much of DM's role, to see his choices as more important than his circumstances. A major goal of the ethics consultants was to reframe DM's predicament for the staff members involved in his care.


Subject(s)
Decision Making , Ethics Consultation , Healthcare Disparities/ethics , Insurance Coverage/ethics , Patient Care Management , Comprehension , Ethics, Clinical , Humans , Patient Care Management/economics , Patient Care Management/ethics , Patient Care Management/methods , Patient Discharge , Socioeconomic Factors
4.
Nurs Adm Q ; 41(4): 376-383, 2017.
Article in English | MEDLINE | ID: mdl-28859007

ABSTRACT

Nurse leaders are responsible for a practice environment that fosters safe, quality patient outcomes through excellence in nursing practice. This article describes a reflective practice intervention in the Cardiac Intensive Care Unit of an urban academic medical center led by the unit nursing director and the hospital's nurse ethicist. The twice monthly case-based discussions, called "Nursing Practice and Ethics Rounds," were attended by staff and unit managers (nurse director, assistant nurse director, and clinical educator) and were facilitated by the nurse ethicist. The purpose of this descriptive qualitative study was to identify nurses' perceptions of the rounds on individual practice, unit practice, and the practice of their peers. Two focus groups were conducted with nurses who attended 3 or more sessions. Staff reported that they felt valued; experienced a decrease in moral distress; and improved empathy with patients, families, and other staff members after the intervention. They also reported better understanding of ethical issues and language to better talk about them. The presence of nurse leaders was valued as affirming the importance of practice development and of witnessing the experience of staff nurses. Finally, the process of reflection was valued for the opportunity it provided to process emotional and intellectual aspects of challenging cases.


Subject(s)
Ethics, Nursing , Leadership , Nurse Administrators/organization & administration , Nursing Staff, Hospital/psychology , Adult , Attitude of Health Personnel , Empathy , Female , Focus Groups , Humans , Male , Middle Aged , Qualitative Research
5.
J Nurs Scholarsh ; 49(4): 445-455, 2017 07.
Article in English | MEDLINE | ID: mdl-28605124

ABSTRACT

BACKGROUND AND PURPOSE: Nurses face complex ethical issues in practice and have to determine appropriate actions. An inability to conceptualize or follow a preferred course of action can give rise to moral uncertainty or moral distress. Both moral uncertainty and moral distress are problematic for nurses and their patients. A program designed to increase nurse confidence in moral decision making, the clinical ethics residency for nurses (CERN), was offered selectively to nurses affiliated with two academic medical centers. This is a report of the analysis of their application essays. DESIGN: Over a 3-year period, 67 application essays were analyzed using conventional content analysis. Applicants comprised one third advanced practice nurses (APNs) and two thirds staff nurses. They were asked to describe their reasons for interest in the CERN and how they would apply the knowledge gained. METHODS: For conventional content analyses, no theoretical presumptions are used; rather, codes are identified from the data in an iterative manner and eventually collapsed into themes. Initially, broad themes were identified by the CERN team. Subsequently, in-depth and recursive readings were completed by a subset of three members, resulting in refinement of themes and subthemes. FINDINGS: The overarching theme identified was "developing abilities to navigate through the 'grey zones' in complex environments." Three subthemes were: (a) nurses encountering patients who are chronically critically ill, culturally diverse, and presenting with complex circumstances; (b) nurses desiring enhanced ethics knowledge and skills to improve quality of care, understand different perspectives, and act as a resource for others; and (c) nurses supporting and facilitating patient-centered ethical decision making. CONCLUSIONS: Findings are consistent with those appearing in the international literature but provide a more cohesive and comprehensive account than previously, and hold promise for the development of educational and policy strategies to address moral distress and uncertainty. CLINICAL RELEVANCE: This study is relevant to clinical practice in its verification of the need nurses have for ethics knowledge, skill refinement, and application through communication. These findings affirmed the challenge that nurses feel in communicating their ethical concerns in an effective and engaging way and their commitment to advocacy and improvement in the quality of care for patients.


Subject(s)
Ethics, Nursing/education , Internship and Residency , Nurses/psychology , Clinical Competence , Female , Humans , Male , Morals , Nurses/statistics & numerical data , Stress, Psychological , Uncertainty
6.
J Clin Ethics ; 27(4): 322-340, 2016.
Article in English | MEDLINE | ID: mdl-28001139

ABSTRACT

During the 1970s and 1980s, legal precedent, governmental recommendations, and professional society guidelines drove the formation of hospital ethics committees (HECs). The Joint Commission on Accreditation of Health Care Organization's requirements in the early 1990s solidified the role of HECs as the primary mechanism to address ethical issues in patient care. Because external factors drove the rapid growth of HECs on an institution-by-institution basis, however, no initial consensus formed around the structure and function of these committees. There are now almost 40 years of empirical studies on the composition, administration, and activities of HECs in the United States. We conducted a systematic review of the available empirical literature on HECs to describe their evolution. As HECs changed over time, they increased their total number of members and percentage of members from nursing and the community. Although physicians increasingly chaired these committees, their presence as a percentage of overall members declined. The percentage of administrative members remained steady, although committees became increasingly likely to have at least one administrative member. HECs were also increasingly likely to report to an administrative body or to the board of trustees or directors rather than to the medical staff. Finally, consultation volume increased steadily over time. There has not, however, been a national survey of the composition of ethics committees, their administration, or volume of consultation in more than 10 years, despite increasing calls for professional standards and quality improvement assessments among HECs.


Subject(s)
Ethics Committees, Clinical/organization & administration , Ethics Consultation/statistics & numerical data , Hospitals , Humans
8.
Surg Infect (Larchmt) ; 15(6): 853-6, 2014 Dec.
Article in English | MEDLINE | ID: mdl-25494230

ABSTRACT

BACKGROUND: Purpura fulminans (PF) is a rare but lethal complication of severe infection. Aggressive surgical debridement of irreversibly devitalized tissue improves survival frequently at the cost of disfigurement. The ethical dilemma of surrogate decision-making for these often incapacitated patients presents a unique challenge for acute care surgeons managing necrotizing soft tissue infections (NSTI). METHODS: Case presentation and scholarly discussion of substituted judgment. RESULTS: A previously healthy 72-y-old fisherman developed PF as a consequence of Neisseria meningiditis severe sepsis requiring bilateral partial finger amputations and bilateral below-knee amputations of the affected gangrenous extremities. Skin biopsy confirmed the clinical impression of disseminated intra-vascular coagulation (DIC). During his 55-d hospitalization, medical decisions were made by a surrogate because the patient's mental status failed to recover to his pre-morbid baseline. A literature review revealed a paucity of data on the accuracy of a health care agent's ability to represent a patient's preferences accurately in elective as well as emergency surgery. CONCLUSIONS: Patients with NSTI and the surgeons who care for them are often confronted with the need to make prompt decisions of radical debridement or amputation. These patients are frequently incapable of making these decisions because of the severity of systemic illness. In such cases, physicians must help patient surrogates or health care agents (when identified) navigate a complex process of acute interventions balancing known or inferred patient's wishes. We urge surgeons to become familiar with the concept of substituted judgment and the challenges of surrogate decision-making.


Subject(s)
Amputation, Surgical , Extremities/surgery , Neisseriaceae Infections/complications , Purpura Fulminans/diagnosis , Purpura Fulminans/surgery , Soft Tissue Infections/diagnosis , Soft Tissue Infections/surgery , Aged , Decision Making , Histocytochemistry , Humans , Judgment , Male , Microscopy , Neisseria meningitidis/isolation & purification , Neisseriaceae Infections/pathology , Purpura Fulminans/pathology
9.
J Nurs Adm ; 44(12): 640-6, 2014 Dec.
Article in English | MEDLINE | ID: mdl-25393140

ABSTRACT

The experience of unaddressed moral distress can lead to nurse attrition and/or distancing from patients, compromising patient care. Nurses who are confident in their ethical decision making abilities and moral agency have the antidote to moral distress for themselves and their colleagues and can act as local or institutional ethics resources. We describe a grant-funded model education program designed to increase ethics competence throughout the institution.


Subject(s)
Ambulatory Care/organization & administration , Burnout, Professional/prevention & control , Interprofessional Relations/ethics , Models, Educational , Morals , Personnel Turnover , Adult , Clinical Competence , Conflict, Psychological , Female , Humans , Job Satisfaction , Male , Middle Aged , Personnel Staffing and Scheduling/ethics , United States
10.
Hastings Cent Rep ; 44(5): 12-20, 2014 09.
Article in English | MEDLINE | ID: mdl-25231657

ABSTRACT

One antidote to moral distress is stronger moral agency-that is, an enhanced ability to act to bring about change. The Clinical Ethics Residency for Nurses, an educational program developed and run in two large northeastern academic medical centers with funding from the Health Resources and Services Administration, intended to strengthen nurses' moral agency. Drawing on Improving Competencies in Clinical Ethics Consultation: An Education Guide, by the American Society for Bioethics and Humanities, and on the goals of the nursing profession, CERN sought to change attitudes, increase knowledge, and develop skills to act on one's knowledge. One of the key insights the faculty members brought to the design of this program is that knowledge of clinical ethics is not enough to develop moral agency. In addition to lecture-style classes, CERN employed a variety of methods based in adult learning theory, such as active application of ethics knowledge to patient scenarios in classroom discussion, simulation, and the clinical practicum. Overwhelmingly, the feedback from the participants (sixty-seven over three years of the program) indicated that CERN achieved transformative learning.


Subject(s)
Education, Nursing/organization & administration , Ethics, Nursing/education , Adult , Communication , Decision Making , Female , Health Knowledge, Attitudes, Practice , Humans , Male , Middle Aged , Morals , Patient Advocacy/ethics , Self Efficacy
11.
Top Stroke Rehabil ; 21(1): 7-11, 2014.
Article in English | MEDLINE | ID: mdl-24521835

ABSTRACT

The challenges families face in making decisions for loved ones after a severe stroke are best supported when the treatment team has the opportunity to share information and perspectives. Weekly multidisciplinary ethics rounds provides a very good forum for just such discussions. Using a case example, this article describes the framework for ethics rounds and its utility in a neuroscience intensive care unit.


Subject(s)
Intensive Care Units/ethics , Interdisciplinary Communication , Neurosciences , Stroke Rehabilitation , Stroke/psychology , Aged, 80 and over , Ethics, Medical , Female , Humans
13.
J Clin Ethics ; 23(3): 234-40, 2012.
Article in English | MEDLINE | ID: mdl-23256404

ABSTRACT

Members of the Clinical Ethics Consultation Affairs Standing Committee of the American Society for Bioethics and Humanities present a collection of insights and recommendations developed from their collective experience, intended for those engaged in the work of healthcare ethics consultation.


Subject(s)
Ethicists/standards , Ethics Consultation/standards , Bioethics , Ethics Committees/standards , Ethics Consultation/organization & administration , Ethics, Medical , Humans , United States
16.
Home Healthc Nurse ; 24(10): 654-61; quiz 670-1, 2006.
Article in English | MEDLINE | ID: mdl-17135844

ABSTRACT

Ethical issues arise in the practice of infusing nursing, and when they do, the home care nurse can find guidance in the code of ethics. This article addresses the importance of the code of ethics and introduces a framework for decision-making to assist the home care nurse in determining a course of action in the face of ethical quandaries.


Subject(s)
Home Infusion Therapy , Terminal Care , Treatment Refusal , Advance Directives/ethics , Advance Directives/psychology , Aged , American Nurses' Association , Codes of Ethics , Decision Making/ethics , Ethical Theory , Home Infusion Therapy/ethics , Home Infusion Therapy/nursing , Home Infusion Therapy/psychology , Humans , International Council of Nurses , Logic , Male , Morals , Nurse's Role/psychology , Patient Advocacy/ethics , Patient Advocacy/psychology , Patient Participation/psychology , Principle-Based Ethics , Problem Solving/ethics , Terminal Care/ethics , Terminal Care/psychology , Treatment Refusal/ethics , Treatment Refusal/psychology , United States
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