[The Elephant in the Room: Integrative Care for Community Hospice Palliative Care in Taiwan: An Example of a Regional Teaching Hospital in Pingtung County].

Taiwan has been an aging society since 2018. As a result, long-term care, end-of-life autonomy, and hospice care have received increasing attention. The government of Taiwan promotes home-based healthcare through the National Health Insurance System to enable the efficient utilization of medical resources and reduce overall medical costs. Taiwan's community hospice and palliative care network is expected to serve as the main care model supplementing partial hospitalization and institutional care. In this article, we review the history of and policies related to hospice and palliative care in Taiwan using a literature review and examining Pingtung County as a case study. The implementation of home-based palliative care is also outlined and policy revisions are proposed. The results are intended to provide a reference for healthcare authorities and medical institutions to promote community hospice and palliative care policies. The integrated care model can enhance the capacity of community-based palliative care, support patients receiving palliative care and their family members and caregivers, and ensure physical and psychological comfort for patients. This model contributes to the realization of older adults' preference for dying at home, which is especially pronounced in cultures where traditional Chinese ideas are deeply rooted.

Teaching and learning in interprofessional ethics education: Tutors' perspectives.

BACKGROUND: Ethical dilemmas that arise in the clinical setting often require the collaboration of multiple disciplines to be resolved. However, medical and nursing curricula do not prioritize communication among disciplines regarding this issue. A common teaching strategy, problem-based learning, could be used to enhance communication among disciplines. Therefore, a university in southern Taiwan developed an interprofessional ethics education program based on problem-based learning strategies. This study described tutors' experience teaching in this program. AIM: To explore the phenomenon of teaching and learning in interprofessional ethics education for medical and nursing students from the perspectives of tutors. DESIGN: Phenomenological qualitative research. METHODS: Medical and nursing students completed a 6-week interprofessional ethics education program moderated by either physician or nurse tutors. At the conclusion of the ethics education program, all 14 tutors were invited to participate in focus group interviews. Among them, six tutors (three nursing tutors and three physician tutors) participated in additional individual interviews. All of the contents from the focus group interviews and individual interviews were recorded and transcribed. Using the phenomenological approach, the phenomenon of teaching and learning in interprofessional ethics education were generated. ETHICAL CONSIDERATION: The study was approved by the Institutional Review Board. FINDINGS: Three themes emerged from the tutors' teaching perspectives, including the instructor's motivation to teach, the use of narrative case scenarios, and the emphasis on improving interprofessional ethics communication. DISCUSSION: Problem-based learning creates an interprofessional communication platform in interprofessional ethics education. The phenomenon of value convergence between tutors and students, between different students' professions, and between different students' professional maturities is observed. CONCLUSION: Problem-based learning is an effective teaching strategy for creating a communication platform for interprofessional ethics education. Ethic curriculum should emphasize motivating instructor, use narrative case scenarios, and focus on interprofessional communication.

[Living With Cancer: Clinical Application of Mindfulness on Cancer-Related Fatigue].

Cancer-related fatigue is the most common and longest-lasting symptom of discomfort experienced by cancer patients. Its effects on patients include physical, psychological, emotional, and cognitive stress, which greatly reduce quality of life. The field of mind-body integrated medicine has improved gradually in recent years, with many evidence-based studies supporting the efficacy of mindfulness as a symptom management strategy for cancer-related fatigue. Based on a review of the literature, this paper introduces the definition of cancer-related fatigue and related assessments and treatments, describes the origin of mindfulness and related concepts, and introduces mindfulness-based empirical treatment strategies for cancer-related fatigue, including mindfulness-based stress reduction and mindfulness-based cognitive therapy, and their effects. The findings are intended to provide clinicians with a reference for the future care of patients with cancer-related fatigue.

Illness Experiences of Advanced Cancer Patients in Taiwan.

The illness experiences of advanced cancer patients are discussed in a Taiwanese cultural context, using an interpretive ethnographic approach (interviews and participant observations) emphasizing holism and symbolic interactionism. A total of 23 advanced cancer patients from different counties in Taiwan were recruited over a 42-month period. The researcher followed their progress as they approached death to better understand their terminal cancer experiences. An interpretive analysis guided by Agar's hermeneutic cycle approach revealed five emic dimensions: feeling the oppression of death, fighting alongside family, intensifying bodily healing efforts, settling unfinished business, and ending the struggle to control pain. Implications for caregivers are discussed.

Psychometric Evaluation of the Capstone Core Competency Scale on Nursing Students in Taiwan.

BACKGROUND: Previous studies have evaluated the competency of newly graduated nurses and nurses. However, most of the instruments used include a large number of items that make completing them a time-consuming process. A brief instrument may be more acceptable and feasible for use in these evaluations. PURPOSE: This study was designed to develop the brief capstone core competency (CCC or 3C) scale and validate its effectiveness in evaluating the academic and practical performance of nursing students enrolled in a bachelor's degree program. METHODS: A cross-sectional study was conducted. The 3C scale was developed in two phases. In Phase I, the items were summed from literature reviews, an expert panel, known-groups validity, test-retest reliability, internal consistency reliability, and exploratory factor analysis. In Phase II, the efficacy of the instrument was confirmed using confirmative factor analysis. Five hundred ninety-six participants participated in the first phase, and 520 participants participated in the second phase. The study period was 2016-2017. RESULTS: The 3C scale includes 24 items distinguished into a three-component structure that accounts for 67.85% of the total variance. The three components include nursing intelligence, nursing humanity, and nursing career. The 3C scale was found to have high levels of internal consistency reliability (.97) and test-retest stability reliability ( r = .97). A significant statistical difference in the performance level was examined between senior and junior nursing students. The hypothesized three-factor model fit index showed χ 2 / df = 1338.25/249, p < .001, goodness-of-fit index = .82, comparative fit index = .90, root mean square error of approximation = .09, and standardized root mean square residual = .06. The participants were found to have excellent nursing humanity competency. CONCLUSIONS: The developed 3C scale exhibited satisfactory reliability and validity for use with nursing students. The 3C scale may be used to evaluate the performance of nursing students during their learning process, and the results may be used to evaluate changes in educational outcomes.

Construct Validity and Reliability of the Chinese Version Personal Adjustment and Role Skills Scale III for Adolescents With Chronic Disease.

PURPOSE: A valid and reliable scale to evaluate psychosocial adjustment in adolescents with chronic disease is prudent for improving their health outcome. This study aimed to develop a Chinese version Personal Adjustment and Role Skills Scale III for Adolescents (C-PARSIII-A) with chronic disease and to examine its construct validity and reliability. DESIGN AND METHODS: A cross-sectional design was conducted. A total of 145 participants were enrolled from a hospital in Taiwan. Content validity, exploratory factor analysis, and corrected item-total correlations were used to explore a factor structure with appropriate items in a C-PARSIII-A. Confirmatory factor analysis was conducted to confirm its factor structure. Cronbach's α and test-retest reliability were performed to examine the reliability. RESULTS: The 18-item C-PARSIII-A with six inter-correlated factors was developed. The standardized factor loadings of each item on its corresponding factor were statistically significant and higher than 0.50; composite reliability and average variance extracted were higher than 0.70 and 0.50 respectively. The correlation coefficients among the six factors in the C-PARSIII-A ranged from 0.10 to 0.84. Cronbach α and test-retest reliability of the C-PARSIII-A were 0.86 and 0.92 respectively. CONCLUSIONS: The six-factor 18-item C-PARSIII-A is supported by sufficient empirical evidence for construct validity and reliability to assess the psychosocial adjustment of adolescents with chronic disease. PRACTICE IMPLICATIONS: Nurses can use the C-PARSIII-A to perform assessment and follow-up on the psychosocial adjustment of adolescents with chronic disease, as well as develop interventions.

Phronesis of nurses: A response to moral distress.

BACKGROUND: As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action. AIM: To describe and analyze the phronesis applied by nurses in the face of moral distress. RESEARCH DESIGN: The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to interpret the nurses' phronesis. PARTICIPANTS: Twenty-seven nurses from Taiwan. ETHICAL CONSIDERATIONS: The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review. FINDINGS: According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse's emotional movement. Action and idea transformation are collectively called phronesis in this study. DISCUSSION: Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress. CONCLUSION: Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress.

Phenomenon of moral distress through the aspect of interpretive interactionism.

BACKGROUND: Most previous studies on moral distress focused on the factors that cause moral distress, paying inadequate attention to the moral conflict of nurses' values, the physician-nurse power hierarchy, and the influence of the culture. RESEARCH OBJECTIVE: To analyze the main causes for moral distress with interpretive interactionism. RESEARCH DESIGN: A qualitative study was adopted. PARTICIPANTS: Through purposeful sampling, 32 nurses from 12 different departments were chosen as the samples. ETHICAL CONSIDERATIONS: Approval from the Institutional Review Board of the Kaohsiung Medical University Hospital. FINDINGS: Moral distress is likely to occur in the following clinical situations: patients have no idea about their diseases; the medical decisions fail to meet the optimum benefit of patients; and patients with terminal cancers are not given a proper death. The reason why nurses become trapped in moral distress is that they fail to achieve moral goodness. Inadequate confidence, the physician-nurse power hierarchy, and the Oriental culture affect nurses' goodness-based intention for patients, which deteriorates moral distress. DISCUSSION: The main cause for moral distress is the moral goodness of nurses. If nurses' goodness-based intention for patients is inconsistent with the moral objective of achieving optimum benefit for patients, it leads to moral distress. Culture is an essential background factor of care for patients. In the Oriental culture, family members influence patients' right to know about their diseases, the choice of treatment, and patients' autonomy of not receiving cardio-pulmonary resuscitation. This results in moral distress in medical care. CONCLUSION: The occurrence of moral distress demonstrates that nurses have moral characteristics such as goodness and caring. It is suggested that appropriate educational strategies can be adopted to weaken the power hierarchy between physicians and nurses and enhance nurses' confidence and cultural sensitivity, so as to reduce the moral distress of nurses.

Moral Distress Model Reconstructed Using Grounded Theory.

BACKGROUND: The problems of nurse burnout and manpower shortage relate to moral distress. Thus, having a good understanding of moral distress is critical to developing strategies that effectively improve the clinical ethical climate and improve nursing retention in Taiwan. PURPOSE: The aim of this study was to reconstruct the model of moral distress using the grounded theory. METHODS: Twenty-five staff nurses at work units who attend to the needs of adult, pediatric, acute, and critical disease or end-of-life-care patients were recruited as participants using theoretical sampling from three teaching hospitals in Taiwan. Data were collected using intensive, 2- to 3-hour interviews with each participant. Audio recordings of the interviews were made and then converted into transcripts. The data were analyzed using the grounded theory. RESULTS: In the clinical setting, the perspective that nurses take toward clinical moral events reflects their moral values, which trigger moral cognition, provocation, and appraisal. The moral barriers that form when moral events that occur in clinical settings contradict personal moral values may later develop into moral distress. In handling moral barriers in the clinical environment, nurses make moral judgments and determine what is morally correct. Influenced by moral efficacy, the consequence may either be a moral action or an expression of personal emotion. Wasting National Health Insurance resources and Chinese culture are key sources of moral distress for nurses in Taiwan. The role of self-confidence in promoting moral efficacy and the role of heterodox skills in promoting moral actions represent findings that are unique to this study. CONCLUSIONS: The moral distress model was used in this study to facilitate the development of future nursing theories. On the basis of our findings, we suggested that nursing students be encouraged to use case studies to establish proper moral values, improve moral cognition and judgment capabilities, and promote moral actions to better handle the regular pressures of moral distress in future clinical or workplace settings. Moreover, a better understanding of moral distress may help retain staff nurses.

[Unity of knowing and action- exploring moral courage in nursing practice].

Ethics is a core value of nursing, and hospital nurses will try, as much as possible, to be "good" in terms of established nursing ethics and values. Nurses learn the value of providing "patient centered care" in school and try to establish relationships of trust with their patients in clinical settings. However, the realities of working in the hospital teaches nurses that actual situations are complex to the point of inducing "ethical dilemmas" and "moral distress" because of the many factors that affect medical decisions regarding individual patients. If nurses could follow their conscience in managing difficult ethical situations with moral courage, they would promote the value of "good nurse" which is innate in both nurses and society. This article defines the parameters of conscience and moral courage, the conditions such should exhibit, strategies nurses should consider, and appropriate nursing training methods. The authors hope to help foster the development of moral courage and create positive practice environments for nursing staff.

The effectiveness of problem-based learning and concept mapping among Taiwanese registered nursing students.

The purpose of this study was to investigate the effectiveness of adopting problem-based learning (PBL) and concept mapping (CM) in the educational programs for Taiwanese registered nursing (RN) students. We used a quasi-experimental design with experimental and control groups to evaluate the effectiveness of PBL-CM in three time schedules: before the course began (pre-test), at the end of the course (post-test), and six months after the end of the course (follow-up test). A convenience sample of 120 RN students participated, 51in the experimental group and 69 in the control group. Finding showed that the experimental group had higher scores than the control group for the Critical-Thinking Scale, Self-Directed Learning Scale, and Students' Performance in PBL Tutorial Sessions Questionnaire at the post-test and follow-up test stages. The PBL-CM increased students' critical-thinking skills and personal accountability for self-directed learning, and it would enhance the skills of independent study, reasoning, group interaction and active participation. This study offers guidelines for new nurse-training programs and continuing nursing education in clinical practice.

[Moral distress and leadership in nursing].

While nursing staff learn the rules of ethical behavior in nursing education programs, they commonly experience confusion, frustration and stress in practice settings due to barriers to moral action faced in the work environment. "Moral distress" is a term used to describe the situation in which a decision-maker cannot carry out an ethical or moral action due to the presence of an obstacle. In this article, we described the meaning of and factors influencing moral distress in nursing work settings in relation to nursing leader management strategies. Goals of the article were to help nursing leaders appreciate their personal beliefs as well as to develop strategies to alleviate emotional distress and promote self-efficacy among nursing staff members. One favorable benefit is expected to be greater retention of nursing staff.