Ethics and frontline nursing during COVID-19: A qualitative analysis.

BACKGROUND: Nurses experienced intense ethical and moral challenges during the COVID-19 pandemic. Our 2020 qualitative parent study of frontline nurses' experiences during the COVID-19 pandemic identified ethics as a cross-cutting theme with six subthemes: moral dilemmas, moral uncertainty, moral distress, moral injury, moral outrage, and moral courage. We re-analyzed ethics-related findings in light of refined definitions of ethics concepts. RESEARCH AIM: To analyze frontline U.S. nurses' experiences of ethics during the COVID-19 pandemic. RESEARCH DESIGN: Qualitative analysis using a directed content methodology. PARTICIPANTS AND RESEARCH CONTEXT: The study included 43 nurses from three major metropolitan academic medical centers and one community hospital in the northeastern, mid-Atlantic, midwestern, and western United States. ETHICAL CONSIDERATIONS: Participant privacy and data confidentiality were addressed. FINDINGS: Moral dilemmas arose from many situations, most frequently related to balancing safety and patient care. Moral uncertainty commonly arose from lacking health information or evidence about options. Moral distress occurred when nurses knew the right thing to do, but were prevented from doing so, including with end-of-life issues. Moral injury (accompanied by suffering, shame, or guilt) occurred after doing, seeing, or experiencing wrongdoing, often involving authority figures. Nurses expressed moral outrage at events and people within and outside healthcare. Despite difficult ethical situations, some nurses exemplified moral courage, sometimes by resisting policies they perceived as preventing compassionate care, guided by thinking about what was best for patients. DISCUSSION: This content analysis of ethics-related subthemes revealed conceptual characteristics and clarified distinctions with corresponding exemplars. Conceptual clarity may inform responses and interventions to address ethical quandaries in nursing practice. CONCLUSIONS: Ethics education in nursing must address the moral dilemmas of pandemics, disasters, and other crises. Nurses need time and resources to heal from trying to provide the best care when no ideal option was available.

Nursing perspectives about the critical gaps in public health emergency response during the COVID-19 pandemic.

INTRODUCTION: The purpose of this qualitative study was to synthesize frontline U.S. nursing perspectives about the current state of U.S. public health emergency preparedness and response. The study findings may inform public health policy change and improve future national pandemic planning and responses. DESIGN: We conducted a secondary thematic qualitative analysis using grounded theory methodology. METHODS: Data collection occurred through semi-structured, in-depth focus groups between July and December 2020, from 43 frontline nurses working in hospitals in four states (Ohio, California, Pennsylvania, and New York). Data were analyzed deductively, aligned with Khan et al.'s Public Health Emergency Preparedness Framework and inductively for emergent themes. RESULTS: Three themes emerged: (1) Validation of the presence of health disparities and inequities across populations; (2) Perceived lack of consistency and coordination of messaging about pandemic policies and plans across all levels; and (3) challenges securing and allocating nursing workforce resources to areas of need. CONCLUSION: From a frontline nursing perspective, this study demonstrates the critical need to address health inequities and inequalities across populations, a consistent national vehicle for communication, and national plan for securing and allocating nursing workforce resources.

Reflections From the Middle: Exploring the Experience of Nurse Managers Across the United States During the COVID-19 Pandemic.

OBJECTIVE: The objective of this multisite study was to explore the professional and personal experiences of US nurse managers (NMs) during the COVID-19 pandemic. BACKGROUND: NMs are the most accessible and visible nurse leaders to the frontline staff during this pandemic. METHODS: Thirty-nine NMs from 5 health systems across the US participated in focus groups in this qualitative study. Data were analyzed using a constant comparative method. RESULTS: Three major themes were identified: challenges, feelings and emotions, and coping. Subthemes emerged within each major theme. CONCLUSION: NMs across the country accepted considerable responsibility at great professional and personal consequence during the pandemic. NMs experienced challenges, ethical dilemmas, and expressed negative emotions. As the usual coping strategies failed, NMs reported that they are considering alternative career choices. This work provided evidence to help senior leaders strategize about mechanisms for reducing managerial dissonance during times of stress.

United States nurses' experiences during the COVID-19 pandemic: A grounded theory.

OBJECTIVE: The objective of this study was to explore nurses' experiences and perceptions at selected United States (U.S.) healthcare sites during the COVID-19 pandemic. BACKGROUND: The COVID-19 pandemic brought rapid changes to the healthcare community. While a few studies have examined the early pandemic experiences of nurses in China and Europe, nurses' experiences across the United States have remained relatively underexplored. DESIGN: A qualitative study design was used. METHODS: Using a constructivist grounded theory methodology and methods, we conducted eight focus groups across four hospital sites in the eastern, midwestern and western United States. Registered nurses with a minimum of six months' experience working in all clinical specialties were eligible. Forty-three nurses participated. Data were analysed iteratively using the constant comparative method. The COREQ guidelines supported the work and reporting of this study. RESULTS: The nurses experiencing a pandemic (NEXPIC) grounded theory emerged positing associations between four interrelated themes: Challenges, Feelings, Coping and Ethics. Nurses reported Challenges associated with changes in the work environment, community and themselves. They expressed more negative than positive feelings. Nurses coped using self-care techniques, and teamwork within the healthcare organisation. Moral dilemmas, moral uncertainty, moral distress, moral injury and moral outrage were ethical issues associated with nurses' Challenges during the pandemic. Moral courage was associated with positive Coping. CONCLUSIONS: Awareness of frontline nurses' complex and interrelated needs may help healthcare organisations protect their human resources. This new theory provides preliminary theoretical support for future research and interventions to address the needs of frontline nurses. RELEVANCE TO CLINICAL PRACTICE: Nurses face added distress as frontline at-risk caregivers. Interventions to promote nurses' ability to cope with personal and professional challenges from the pandemic and address ethical issues are needed to protect the nursing workforce. This study offers a new substantive theory that may be used to underpin future interventions.

Electronic Health Record Transition: The Patient Experience.

Use of the EHR at the bedside is now commonplace, and some fear this may compromise their relationship with the patient. The purpose of this study was to assess the impact of a transition of an EHR on the patient experience. Three non-equivalent groups consisting of 55 patients responded to instrument questions at three distinct time points: baseline prior to transition and twice after the transition at 6 weeks and 6 months. Questions investigated the point-of-care computer use, user's comfort, and impact on patient relationship with a nurse or provider. Patients perceived more use of the computer by Nurses and a declining use by Others. Nurses remained comfortable using the computer over time, and the perception of Others declined. Nurses were perceived 2.3 times more likely than Others as changing the patient relationship and two times higher with a positive impact. The transition in the EHR did not seem to affect the overall patient experience; however, results should be viewed with caution given the limitations of this study and the dearth of evidence. Evidence-based guidelines for EHR integration may be helpful in the future to address inpatient encounters with all clinicians.

Function-Focused Goal Attainment and Discharge Outcomes in Hospitalized Persons With Dementia.

Hospitalized persons with dementia are at higher risk for functional decline and cognitive loss related to delirium. Family-centered, function-focused care (Fam-FFC) engages the family care partner in education and active participation in function-focused goal setting, implementation, and evaluation to support delirium prevention and abatement and return to baseline physical function. The purpose of the current study was to examine the association of function-focused goal attainment with two discharge outcomes, return to baseline physical function and delirium severity at discharge, in hospitalized persons with dementia. In the ongoing Fam-FFC clinical trial, the majority of goals (N = 433) developed by 134 care partner/patient dyads and nurses address mobility, cognitive stimulation, and self-care. Regression techniques demonstrated that goal attainment was significantly associated with return to baseline function (B = 0.826, Wald = 4.17 [1], p = 0.041) and lower delirium severity at discharge (B = 0.175, t = 2.239, p = 0.027). Results support the contribution of family engagement in promoting functional recovery of hospitalized persons with dementia. [Journal of Gerontological Nursing, 47(9), 13-20.].

Increasing nursing research capacity: The roles and contributions of nurse scientists within healthcare systems in the Greater Philadelphia region.

PhD prepared nurse scientists within healthcare systems are uniquely positioned to advance nursing science through research and evidence-based practice (EBP) initiatives due to their ability to closely collaborate with nurses and other healthcare professionals in the clinical setting. The purpose of this paper is threefold: 1) to describe the roles and contributions of Nurse Scientists, from their perspectives, in four different health care systems in the Greater Philadelphia area, three of which are Magnet® designated hospitals; 2) to highlight organizational approaches to increase nursing research and EBP capacity; and 3) to explore strategies that Nurse Scientists used to overcome barriers to build nursing research capacity. Nurse Scientists employed in these healthcare systems share many of the same essential roles and contributions focused on developing nursing research and EBP initiatives through education and mentorship of clinical nurses, conduct and oversight of independent research, and dissemination activities. With supportive executive nurse leadership, the Nurse Scientists within each healthcare system employed different strategies to overcome barriers in building nursing research and EBP capacity. Nurse scientists within healthcare settings have potentially powerful positions to generate and apply new knowledge to guide nursing practice and improve outcomes.

Gastrostomy tube placement in patients with advanced dementia or near end of life.

Based on current scientific literature, gastrostomy tube (G-tube) placement or other long-term enteral access devices should be withheld in patients with advanced dementia or other near end-of-life conditions. In many instances healthcare providers are not optimally equipped to implement this recommendation at the bedside. Autonomy of the patient or surrogate decision maker should be respected, as should the patient's cultural, religious, social, and emotional value system. Clinical practice needs to address risks, burdens, benefits, and expected short-term and long-term outcomes in order to clarify practice changes. This paper recommends a change in clinical practice and care strategy based on the results of a thorough literature review and provides tools for healthcare clinicians, particularly in the hospital setting, including an algorithm for decision making and a checklist to use prior to the placement of G-tubes or other long-term enteral access devices. Integrating concepts of patient-centered care, shared decision making, health literacy, and the teach-back method of education enhances the desired outcome of ethical dilemma prevention. The goal is advance care planning and a timely consensus among health team members, family members, and significant others regarding end-of-life care for patients who do not have an advance directive and lack the capacity to advocate for themselves. Achieving this goal requires interdisciplinary collaboration and proactive planning within a supportive healthcare institution environment.

Experiences of faculty and students using an audience response system in the classroom.

The advent of innovative technologies, such as the audience response system, provides an opportunity to engage students and enhance learning. Based on their experiences, three nursing faculty evaluated the use of an audience response system in four distinct nursing courses through the use of informal survey results. When using the audience response system, the faculty experienced an increased perception of student attentiveness and engagement, high level of class attendance, and enhanced learning. Faculty feelings were mixed concerning the burden in adapting to increased classroom time and increased preparation time. Students' perception of the value of audience response system use was mostly positive, except when responses were included as part of the grade. The majority of the students indicated that use of the audience response system enhanced learning and was a helpful learning method when used with NCLEX-style questions. Overall, faculty believed that the benefits of student engagement and enhanced learning outweighed the burdens of incorporating this new technology in the classroom.

From means to ends: artificial nutrition and hydration.

The withdrawal, withholding, or implementation of life-sustaining treatments such as artificial nutrition and hydration challenge nurses on a daily basis. To meet these challenges, nurses need the composite skills of moral and ethical discernment, practical wisdom and a knowledge base that justifies reasoning and actions that support patient and family decision making. Nurses' moral knowledge develops through experiential learning, didactic learning, and deliberation of ethical principles that merge with moral intuition, ethical codes, and moral theories. Only when a nurse becomes skilled and confident in gathering empiric and ethical knowledge can he or she fully act as a moral agent in assisting families faced with making highly emotional decisions regarding the provision, withholding, or withdrawal of artificial nutrition and hydration.

The artificial nutrition debate: still an issue... after all these years.

Debate over withdrawal or withholding of artificial nutrition appeared a distant discussion until the furor over the Schiavo case and a Papal Allocation reignited this ethical dilemma. The purpose of this article is to provide a review of the bioethical opinion regarding artificial nutrition, as published in the Hastings Center Report from 1971 until 2007. A clinical and religious history of the evolution and use of artificial nutrition prefaces the review containing common themes and categories framed within a chronology of bioethical and legal events. Finally, an interpretative philosophical discussion is offered on the resurgence of the ethical dilemma concerning withdrawal or withholding of artificial nutrition. Through a combination of classic content analysis and grounded theory, 8 inductively derived categories emerged from a sample of 63 articles/letters with a primary focus on artificial nutrition, enteral nutrition or parenteral nutrition. These categories included illness/treatment trajectory, personhood, family, provider, cost, religion, legal, and ethics and morality. In more than 35 years, surprisingly little has changed with regard to withdrawal or withholding of artificial nutrition. As the Schiavo case revealed, despite a sense in bioethics of a firm consensus about handling the withdrawal of food and water, many are still searching for answers to this dilemma.

Advance directives at end-of-life: nursing home resident preferences for artificial nutrition.

OBJECTIVE: Nursing homes are increasingly the place where many Americans die. Thus, advance directives are critical to the preservation of the autonomous wishes at end-of-life. The purpose of this paper is to determine if preferences for artificial nutrition, as stated in the advance directives of nursing home residents, are honored in the last 2 months of life. DESIGN: Secondary analysis. SETTING: Six Maryland community nursing homes. PARTICIPANTS: Fifty-seven consented residents (age 62 to 98) from the parent study who died during the study period. MEASUREMENTS: Retrospective document review including advance directives and clinical care provided in the last 2 months of life. RESULTS: Most of the nursing home residents in this sample refused feeding tubes, and these preferences were honored during the last 2 months of life (93%), despite some (17% to 26%) with documented weight loss. A small percentage (8.8%) of residents received feeding tubes at end-of-life and, of those, only 1 was consistent with advance directive preferences. Most advance directives in this study included feeding tube preferences. CONCLUSION: In this nursing home sample, advance directives were significant documents guiding decisions on artificial nutrition, and feeding tubes were in fact uncommon at the end of life. The study suggests that advance care planning, quality palliative care training, and administrative support are necessary for the honoring of preferences. Future research is needed to examine more broadly tube-feeding practices and prevalence in nursing homes.