Nursing students' experiences of moral uncertainty in the context of global health practicums.

More students than ever are electing to take part in international practicums from health-related disciplines. With the goal of better understanding the moral experiences and ethical implications of global health practicums (GHPs), the purpose of this Interpretive Descriptive study was to examine the moral uncertainty of nursing students from one university in Canada. Seventeen nurses who had participated in a GHP in their undergraduate nursing program participated in semi-structured interviews. Data were analyzed inductively using constant comparative data analysis techniques, and a thematic account of participants' experiences was developed. Findings suggest that nursing students experienced considerable amounts of moral uncertainty during their GHP. Most often, participants' experiences of uncertainty stemmed from a misalignment between their expectations and reality, including encountering different approaches to healthcare, being situated in new cultural and clinical care environments, and grappling with how best to stay within one's scope of student professional practice. Participants inconsistently reflected on these experiences, which may present a missed opportunity for professional growth through the development of a heightened social consciousness. Educators can facilitate this process by implementing robust predeparture training for GHPs, clarifying program objectives, and providing clinical debriefing.

Constructing Good Nursing Practice for Medical Assistance in Dying in Canada: An Interpretive Descriptive Study.

Nurses play a central role in Medical Assistance in Dying (MAiD) in Canada. However, we know little about nurses' experiences with this new end-of-life option. The purpose of this study was to explore how nurses construct good nursing practice in the context of MAiD. This was a qualitative interview study using Interpretive Description. Fifty-nine nurses participated in semi-structured telephone interviews. Data were analyzed inductively. The findings illustrated the ways in which nurses constructed artful practice to humanize what was otherwise a medicalized event. Registered nurses and nurse practitioners described creating a person-centered MAiD process that included establishing relationship, planning meticulously, orchestrating the MAiD death, and supporting the family. Nurses in this study illustrated how a nursing gaze focused on relationality crosses the moral divides that characterize MAiD. These findings provide an in-depth look at what constitutes good nursing practice in MAiD that can support the development of best practices.

Riding an elephant: A qualitative study of nurses' moral journeys in the context of Medical Assistance in Dying (MAiD).

AIMS AND OBJECTIVES: To describes nurses' moral experiences with Medical Assistance in Dying in the Canadian context. BACKGROUND: Nurses perform important roles in Medical Assistance in Dying in Canada and do so within a unique context in which Medical Assistance in Dying is provided through healthcare services and where accessibility is an important principle. International literature indicates that participating in Medical Assistance in Dying can be deeply impactful for nurses and requires a high degree of moral sense-making. DESIGN: A qualitative interview study guided by Interpretive Description using the COREQ checklist. RESULTS: Fifty-nine nurses from across Canada participated in the study. The decision to participate in Medical Assistance in Dying was influenced by family and community, professional experience and nurses' proximity to the act of Medical Assistance in Dying. Nurses described a range of deep and sometimes conflicting emotional reactions provoked by Medical Assistance in Dying. Nurses used a number of moral waypoints to make sense of their decision including patient choice, control and certainty; an understanding that it was not about the nurse; a commitment to staying with patients through suffering; consideration of moral consistency; issues related to the afterlife; and the peace and gratitude demonstrated by patients and families. DISCUSSION: The depth of nurses' intuitional moral responses and their need to make sense of these responses are consistent with Haidt's theory of moral experience in which individuals use reasoning primarily to explain their moral intuition and in which moral change occurs primarily through compassionate social interaction. Further, work on the moral identity of nursing provides robust explanation of how nurses' moral decisions are contextually and relationally mediated and how they seek to guard patient vulnerability, even at their own emotional cost. CONCLUSION: Medical Assistance in Dying is impactful for nurses, and for some, it requires intensive and ongoing moral sense-making. RELEVANCE TO CLINICAL PRACTICE: There is a need to provide support for nurses' moral deliberation and emotional well-being in the context of Medical Assistance in Dying care.

The rocks and hard places of MAiD: a qualitative study of nursing practice in the context of legislated assisted death.

BACKGROUND: Medical Assistance in Dying (MAiD) was legalized in Canada in June, 2016. The Canadian government's decision to legislate assisted dying, an approach that requires a high degree of obligation, precision, and delegation, has resulted in unique challenges for health care and for nursing practice. The purpose of this study was to better understand the implications of a legislated approach to assisted death for nurses' experiences and nursing practice. METHODS: The study used a qualitative approach guided by Interpretive Description. Semi-structured interviews were conducted with 59 registered nurses and nurse practitioners. Interviews were audio-recorded, transcribed, and managed using qualitative analysis software. Analysis followed a procedure of data immersion, open coding, constant comparative analysis, and the construction of a thematic and interpretive account. RESULTS: Nurses in this study described great variability in how MAiD had been enacted in their work context and the practice supports available to guide their practice. The development of systems to support MAiD, or lack thereof, was largely driven by persons in influential leadership positions. Workplaces that supported a range of nurses' moral responses to MAiD were most effective in supporting nurses' well-being during this impactful change in practice. Participants cited the importance of teamwork in providing high quality MAiD-related care; although, many worked without the benefit of a team. Nursing work related to MAiD was highly complex, largely because of the need for patient-centered care in systems that were not always organized to support such care. In the absence of adequate practice supports, some nurses were choosing to limit their involvement in MAiD. CONCLUSIONS: Data obtained in this study suggested that some workplace contexts still lack the necessary supports for nurses to confidently meet the precision required of a legislated approach to MAiD. Without accessible palliative care, sufficient providers, a supportive team, practice supports, and a context that allowed nurses to have a range of responses to MAiD, nurses felt they were legally and morally at risk. Nurses seeking to provide the compassionate care consistent with such a momentous moment in patients' lives, without suitable supports, find themselves caught between the proverbial rock and hard place.

Nursing and euthanasia: A narrative review of the nursing ethics literature.

BACKGROUND: Medical Assistance in Dying, also known as euthanasia or assisted suicide, is expanding internationally. Canada is the first country to permit Nurse Practitioners to provide euthanasia. These developments highlight the need for nurses to reflect upon the moral and ethical issues that euthanasia presents for nursing practice. PURPOSE: The purpose of this article is to provide a narrative review of the ethical arguments surrounding euthanasia in relationship to nursing practice. METHODS: Systematic search and narrative review. Nine electronic databases were searched using vocabulary developed from a stage 1 search of Medline and CINAHL. Articles that analysed a focused ethical question related to euthanasia in the context of nursing practice were included. Articles were synthesized to provide an overview of the literature of nursing ethics and euthanasia. ETHICAL CONSIDERATIONS: This review was conducted as per established scientific guidelines. We have tried to be fair and respectful to the authors discussed. FINDINGS: Forty-three articles were identified and arranged inductively into four themes: arguments from the nature of nursing; arguments from ethical principles, concepts and theories; arguments for moral consistency; and arguments from the nature of the social good. Key considerations included nursing's moral ontology, the nurse-patient relationship, potential impact on the profession, ethical principles and theories, moral culpability for acts versus omissions, the role of intention and the nature of the society in which euthanasia would be enacted. In many cases, the same assumptions, values, principles and theories were used to argue both for and against euthanasia. DISCUSSION: The review identified a relative paucity of literature in light of the expansion of euthanasia internationally. However, the literature provided a fulsome range of positions for nurses to consider as they reflect on their own participation in euthanasia. Many of the arguments reviewed were not nursing-specific, but rather are relevant across healthcare disciplines. Arguments explicitly grounded within the nature of nursing and nurse-patient relationships warrant further exploration.

Shades of gray: Conscientious objection in medical assistance in dying.

With the advent of legalized medical assistance in dying [MAiD] in Canada in 2016, nursing is facing intriguing new ethical and theoretical challenges. Among them is the concept of conscientious objection, which was built into the legislation as a safeguard to protect the rights of healthcare workers who feel they cannot participate in something that feels morally or ethically wrong. In this paper, we consider the ethical complexity that characterizes nurses' participation in MAiD and propose strategies to support nurses' moral reflection and imagination as they seek to make sense of their decision to participate or not. Deconstructing the multiple and sometimes conflicting ethical and professional obligations inherent in nursing in such a context, we consider ways in which nurses can sustain their role as critically reflective moral agents within a context of a relational practice, serving the diverse needs of patients, families, and communities, as Canadian society continues to evolve within this new way of engaging with matters of living and dying.

But it's legal, isn't it? Law and ethics in nursing practice related to medical assistance in dying.

In June 2015, the Supreme Court of Canada struck down the Criminal Code's prohibition on assisted death. Just over a year later, the federal government crafted legislation to entrench medical assistance in dying (MAiD), the term used in Canada in place of physician-assisted death. Notably, Canada became the first country to allow nurse practitioners to act as assessors and providers, a result of a strong lobby by the Canadian Nurses Association. However, a legislated approach to assisted death has proven challenging in a number of areas. Although it facilitates a degree of accountability, precision and accessibility, it has also resulted in particular challenges negotiating the diverse perspectives of such a morally contentious act. One of these challenges is the tendency to conflate what is legal and what is moral in a modern liberal constitutionalism that places supreme value on autonomy and choice. Such a conflation tends to render invisible the legal and moral/ethical considerations necessary for nurses and nurse practitioners to remain ethical actors. In this paper, we introduce this conflation and then discuss the process of lawmaking in Canada, including the legalization of MAiD and the contributions of nursing to that legalization. We then engage in a hypothetical dialogue about the legal and moral/ethical implications of MAiD for nursing in Canada. We conclude with an appeal for morally sustainable workspaces that, when implementing MAiD, appropriately balance patient choices and nurses' moral well-being.

Ethical, Policy, and Practice Implications of Nurses' Experiences With Assisted Death: A Synthesis.

The conceptualization of assisted death as an act performed by physicians has resulted in a lack of attention to nurses' roles and experiences with the processes that surround an assisted death. In this article, we synthesize evidence from 6 articles focusing on the experiences of 55 nurses from Canada, Belgium, and the Netherlands, with relevant ethical and policy implications derived from the literature. Nurses have a central role in negotiating inquiries about assisted death and in providing wraparound care for patients, families, and other health care providers. This role is impactful for nurses and requires significant personal and professional moral work.

Medical Assistance in Dying: A Review of Canadian Nursing Regulatory Documents.

Canada's legalization of Medical Assistance in Dying (MAiD) in 2016 has had important implications for nursing regulators. Evidence indicates that registered nurses perform key roles in ensuring high-quality care for patients receiving MAiD. Further, Canada is the first country to recognize nurse practitioners as MAiD assessors and providers. The purpose of this article is to analyze the documents created by Canadian nursing regulatory bodies to support registered nurse and nurse practitioner practice in the political context of MAiD. A search of Canadian provincial and territorial websites retrieved 17 documents that provided regulatory guidance for registered nurses and nurse practitioners related to MAiD. Responsibilities of registered nurses varied across all documents reviewed but included assisting in assessment of patient competency, providing information about MAiD to patients and families, coordinating the MAiD process, preparing equipment and intravenous access for medication delivery, coordinating and informing health care personnel related to the MAiD procedure, documenting nursing care provided, supporting patients and significant others, and providing post death care. Responsibilities of nurse practitioners were identified in relation to existing legislation. Safety concerns cited in these documents related to ensuring that nurses understood their boundaries in relation to counseling versus informing, administering versus aiding, ensuring safeguards were met, obtaining informed consent, and documenting. Guidance related to conscientious objection figured prominently across documents. These findings have important implications for system level support for the nursing role in MAiD including ongoing education and support for nurses' moral decision making.

Resources for Educating, Training, and Mentoring Nurses and Unregulated Nursing Care Providers in Palliative Care: A Review and Expert Consultation.

BACKGROUND: Nurses and nursing care providers provide the most direct care to patients at end of life. Yet, evidence indicates that many feel ill-prepared for the complexity of palliative care. OBJECTIVE: To review the resources required to ensure adequate education, training, and mentorship for nurses and nursing care providers who care for Canadians experiencing life-limiting illness and their families. METHODS: This is a systematic search and narrative review in the Canadian context. RESULTS: Six previous reviews and 26 primary studies were identified. Studies focusing on regulated nurses indicated that even amid variability in content, delivery methods, and duration, palliative education improves nurses' knowledge, confidence, attitudes, and communication abilities, and decreases nurses' stress. Results from palliative education in undergraduate curriculum were less definitive. However, studies on palliative simulation in undergraduate education suggest that it improves knowledge and confidence. Studies focusing on educating nursing care providers, either alone or in collaboration with regulated nurses, indicated positive outcomes in knowledge, confidence, communication, identification of clients who are dying, abilities to interact with patients and families, and a better understanding of their own contributions to care. Curricular resources in Canada have been developed. However, there is no dedicated and funded capacity-building strategy. DISCUSSION: Resources exist to support palliative education for nurses and nursing care providers. Furthermore, the evidence suggests good outcomes from this education. However, there is no dedicated strategy for implementing those resources. Furthermore, there is little evidence of the critical role of knowledge translation in preparing nurses and nursing care providers for evidence-informed palliative practice.

Volunteer navigation partnerships: Piloting a compassionate community approach to early palliative care.

BACKGROUND: A compassionate community approach to palliative care provides important rationale for building community-based hospice volunteer capacity. In this project, we piloted one such capacity-building model in which volunteers and a nurse partnered to provide navigation support beginning in the early palliative phase for adults living in community. The goal was to improve quality of life by developing independence, engagement, and community connections. METHODS: Volunteers received navigation training through a three-day workshop and then conducted in-home visits with clients living with advanced chronic illness over one year. A nurse navigator provided education and mentorship. Mixed method evaluation data was collected from clients, volunteer navigators, the nurse navigator, and other stakeholders. RESULTS: Seven volunteers were partnered with 18 clients. Over the one-year pilot, the volunteer navigators conducted visits in home or by phone every two to three weeks. Volunteers were skilled and resourceful in building connections and facilitating engagement. Although it took time to learn the navigator role, volunteers felt well-prepared and found the role satisfying and meaningful. Clients and family rated the service as highly important to their care because of how the volunteer helped to make the difficult experiences of aging and advanced chronic illness more livable. Significant benefits cited by clients were making good decisions for both now and in the future; having a surrogate social safety net; supporting engagement with life; and ultimately, transforming the experience of living with illness. Overall the program was perceived to be well-designed by stakeholders and meeting an important need in the community. Sustainability, however, was a concern expressed by both clients and volunteers. CONCLUSIONS: Volunteers providing supportive navigation services during the early phase of palliative care is a feasible way to foster a compassionate community approach to care for an aging population. The program is now being implemented by hospice societies in diverse communities across Canada.

Health Care Chaplaincy: A Scoping Review of the Evidence 2009-2014.

There is a growing body of evidence investigating chaplaincy services. The purpose of this scoping review was to examine the empirical literature specific to the role of chaplaincy within health care published since 2009. Electronic searches of four databases were conducted in August 2015. After screening, 48 studies were retained and reviewed. Four themes emerged: experiences and perceptions of the health care chaplain (n = 15), chaplain practice (n = 9), emerging areas of health care chaplaincy (n = 16), and outcome studies (n = 8). Studies were diverse in topics covered, methods, national contexts, and clinical settings. The majority were descriptive in nature. Evidence continues to demonstrate a relationship between chaplains and increased patient satisfaction. Nascent areas of research include chaplain's role with diverse populations, involvement in clinical ethics, and confidence with research and evidence-based practice. Few conclusions can be drawn from the limited evidence on the outcomes of chaplain interventions.