Empirical developments in retraction.

This study provides current data on key questions about retraction of scientific articles. Findings confirm that the rate of retractions remains low but is increasing. The most commonly cited reason for retraction was research error or inability to reproduce results; the rate from research misconduct is an underestimate, since some retractions necessitated by research misconduct were reported as being due to inability to reproduce. Retraction by parties other than authors is increasing, especially for research misconduct. Although retractions are on average occurring sooner after publication than in the past, citation analysis shows that they are not being recognised by subsequent users of the work. Findings suggest that editors and institutional officials are taking more responsibility for correcting the scientific record but that reasons published in the retraction notice are not always reliable. More aggressive means of notification to the scientific community appear to be necessary.

Review of measurement instruments in clinical and research ethics, 1999-2003.

Every field of practice has the responsibility to evaluate its outcomes and to test its theories. Evidence of the underdevelopment of measurement instruments in bioethics suggests that attending to strengthening existing instruments and developing new ones will facilitate the interpretation of accumulating bodies of research as well as the making of clinical judgements. A review of 65 instruments reported in the published literature showed 10 with even a minimal level of psychometric data. Two newly developed instruments provide examples of the full use of psychometric and ethical theory. Bioethicists use a wide range of methods for knowledge development and verification; each method should meet stringent standards of quality.

The dean of nursing as arbiter, antagonist, and advocate.

Any professional and especially an administrative role is framed in two ways: (1) by a context--the set of ideas, institutional structures, and politics in place at a particular time, and (2) by the set of competencies that senior managers must develop. The context is a set of social expectations within which the role operates and, in the case of the role of dean, reflects the current development of nursing as an academic discipline and of the universities of which it is a part. Since nursing became a university-based discipline, deans of major schools of nursing have had to do path-breaking work in integrating the discipline/profession into universities. This work is not yet complete, and these roles will continue to require high levels of the managerial competencies.

Nurses' ethical conflicts: what is really known about them?

The purpose of this article is to report what can be learned about nurses' ethical conflicts by the systematic analysis of methodologically similar studies. Five studies were identified and analysed for: (1) the character of ethical conflicts experienced; (2) similarities and differences in how the conflicts were experienced and how they were resolved; and (3) ethical conflict themes underlying four specialty areas of nursing practice (diabetes education, paediatric nurse practitioner, rehabilitation and nephrology). The predominant character of the ethical conflicts was disagreement with the quality of medical care given to patients. A significant number of ethical conflicts were experienced as 'moral distress', the resolution of which was variable, depending on the specialty area of practice. Ethical conflict themes underlying the specialty areas included: differences in the definition of adequacy of care among professionals, the institution and society; differences in the philosophical orientations of nurses, physicians and other health professionals involved in patient care; a lack of respect for the knowledge and expertise of nurses in specialty practice; and difficulty in carrying out the nurse's advocacy role for patients.

Ethical and human rights concerns of Connecticut nurses: survey and implications for the profession.

A survey of a random sample of Connecticut registered nurses' experiences with issues of ethics and human rights found a strong focus on protecting patient rights and dignity, adequacy of staffing patterns, informed consent, and respecting advance directives. Ethics committees were commonly available but were infrequently used. Participants reported high levels of ethics education but also desired more such education. The character of the issues is consistent with other studies and largely reflects conflicts over which nurses do not have independent control. Consideration is given to issues of nurses' moral agency in health care organizations.

Ethical conflicts experienced by certified pediatric nurse practitioners in ambulatory settings.

INTRODUCTION: The purpose of this descriptive study was to (a) identify the types of ethical conflicts and their resolutions reported by a group of certified pediatric nurse practitioners (CPNPs) in their ambulatory practice and (b) to examine demographic, educational, and practice-setting factors associated with these conflicts. METHOD: Five hundred fifty-nine CPNPs, identified by the National Association of Pediatric Nurse Associates and Practitioners, received survey questionnaires in the mail and were asked to participate by describing an ethical conflict in their practice. Questionnaires were completed by 118 CPNPs. Each ethical conflict was analyzed according to a four content analysis classification system to capture multiple relevant meanings. The relationship between types of ethical conflicts and demographic, educational, and practice-setting variables was examined. RESULTS: One third (34%) of the perceived ethical conflicts fell in the child/parent/practitioner relationship category. Most conflicts (31%) were experienced as a moral dilemma where 2 or more clear moral principles apply but they support mutually inconsistent courses of action. Most ethical conflicts (22%) were unresolved. DISCUSSION: Understanding the nature of ethical conflicts that CPNPs are experiencing in ambulatory settings is important. Professional and institutions/agencies need to collaborate on how to initiate appropriate ethics education and consultation for professional staff to recognize, discuss, and resolve ethical conflicts in the workplace.

Ethical conflicts reported by certified registered rehabilitation nurses.

The purpose of this study was to identify the types of ethical conflict reported by certified registered rehabilitation nurses (CRRNs) and their relationship to demographic, educational, and practice-setting variables. Ethical conflicts expressed by CRRNs in active practice in Maryland, Virginia, and the District of Columbia were analyzed according to four themes. Disagreements about medical or institutional practice, patients' rights, and payment issues were the most frequent practice contexts for ethical conflicts, reflecting these nurses' considerable underlying concerns about resource allocation in rehabilitation practice. Participants believed that 60% of the ethical conflicts were resolved, frequently through discussions with other team members and patients' family members. Ethics committees and consultants were used infrequently. There were no statistically significant relationships between the kinds of conflicts or their resolution and the participants' demographic, educational, and practice-setting variables.

Measurement characteristics of the levels of institutionalization scales: examining reliability and validity.

The Level of Institutionalization (LoIn) scales were developed to assess the extent to which a health promotion program has become integrated into a health care organization. The instrument was designed specifically to measure the amount of routinization and niche saturation of four subsystems (production, maintenance, supportive, and managerial) believed to make up an organization. In this study, the LoIn scales were completed for diabetes programs in 102 general hospitals and 30 home health agencies in Maryland and Pennsylvania. Reliability estimates across the four subsystems for routines (alpha = .61) and for niche saturation (alpha = .44) were substandard. Average correlation among the four subsystems for routines was .67, and among the four subsystems for niche saturation was .38, indicating moderate to large amounts of shared variance among subsystems and challenging claims of discriminant validity. Given these large correlations and a poor fit when testing the eight-factor model, higher-order confirmatory factor analyses were carried out. Results supported the existence of two second-order factors. When collapsed into two factors, the reliabilities were adequate (routines alpha = .90; niche saturation alpha = .80). Criterion-related validity also was found between length of program existence and the routine factor.

Ethical conflicts reported by registered nurse/certified diabetes educators: a replication.

The purpose of this study was to identify types of ethical conflicts reported by certified diabetes educators who are also registered nurses (RN/CDEs) and to examine their relationship with demographic, educational and practice setting variables. This study is a replication of an earlier pilot study. Ethical conflicts expressed by RN/CDEs in active practice in New York and Pennsylvania were analysed according to four themes. Disagreement with medical practice was by far the most dominant clinical context for the conflicts (61%), as it had been in the pilot study (75%). Participants believed that 32% of the ethical conflicts were resolved. Ethics committees and consultants were very rarely used. Of the relationships between the kinds of conflicts and their resolution, and demographic, educational and practice setting variables of the participants, only kind of position was significantly (P < 0.005) related to practice context of the ethical conflict.

Diabetes education infrastructure and capacity in hospitals and home health agencies in Maryland and Pennsylvania.

In this study, questionnaire data were described regarding diabetes education program capacity in Maryland and Pennsylvania hospitals, health maintenance organizations (HMOs), and home health agencies (HHAs). Hospitals, HMOs, and HHAs in each state were asked to indicate whether they currently have a diabetes education program and, if not, whether they had such a program anytime within the past 10 years. Home health agencies were less likely to have had programs in the past and more likely to have recently established diabetes education programs. About half of hospitals currently without programs had a program sometime within the past 10 years. Hospitals in Maryland and Pennsylvania responded similarly; Pennsylvania HHAs were more likely to report having diabetes education programs than HHAs in Maryland. On the average, programs showed moderate levels of institutionalization. Respondents to the questionnaire believed that their programs would be sustained; these projections appeared to not be sensitive to availability of reimbursement.

Studies of ethical conflicts by nursing practice settings or roles.

This article summarizes the body of research about ethical conflicts described by nurses in various fields of practice and recommends direction for the use and extension of this information. Twenty-three studies that fit criteria for inclusion were located. As a group, studies use inconsistent terminology, pay little attention to measurement characteristics of the instruments used, and do not use explanatory theory about how and why ethical conflicts develop or are experienced. Several studies of nurses practicing in community and home care settings, in intensive care units, and in administrative roles show some common areas of ethical conflict. Studies of ethical conflicts can be used as a basis for improving practice.

Ethical conflicts reported by Certified Nephrology Nurses (CNNs) practicing in dialysis settings.

OBJECTIVE: The purpose of the investigators was to describe and classify ethical conflicts experienced by Certified Nephrology Nurses (CNNs) practicing in dialysis settings in four eastern states and the District of Columbia, and to explore associated demographic, educational, and practice setting factors associated with these ethical conflicts. DESIGN: A descriptive survey design was used. SAMPLE/SETTING: All members of the American Nephrology Nurses Association (ANNA) who were CNNs working in Maryland, Virginia, and the District of Columbia, and a random sample of those in New York State and Pennsylvania were contacted. METHODS: Those CNNs working in dialysis settings were asked to complete the Demographic Data Form and the Moral Conflict Questionnaire developed by Fry (1990). Eighty-eight met inclusion criteria, agreed to participate, and described ethical conflicts. RESULTS: By far the most common practice context for the described ethical conflicts were decisions about discontinuation or initiation of dialysis (69%). Participants were clear about the moral problem and ethical principles involved. CONCLUSIONS: Participants reported being involved in serious ethical conflicts about patient care. Since two-thirds were not resolved, further research should investigate whether existing mechanisms in practice settings for resolution of ethical conflicts are not working or are not being used by nurses.

Cardiac rehabilitation in the elderly: improving effectiveness.

Heart disease is a major cause of mortality and morbidity among adults who are older than 65 years of age. One-third of cardiac operations on adults in the United States are performed on patients who are more than 65 years old, and almost half of the hospitalized candidates for an outpatient cardiac rehabilitation programs are in the older patient population. Structured educational program that include exercise and modification of risk factors have been shown to reduce the risk of subsequent coronary events; however, studies show that older adults enroll in these programs at a significantly lower rate than do patients in other age groups. Nurses and other healthcare professionals must eliminate barriers to participation and adapt their programs to meet the needs of older adults with cardiac disease to reduce morbidity, enhance functioning, and improve quality of life. In this article, the authors describe current knowledge about the efficacy and use of cardiac education and rehabilitation in elderly patients and suggest implications for future practice and research.

Ethical conflicts reported by registered nurse/certified diabetes educators.

The purpose of this pilot study was to identify types of ethical conflicts reported by Certified Diabetes Educators who also are Registered Nurses (RN/CDEs). Ethical conflicts expressed by RN/CDEs in active practice in Maryland, Virginia, and the District of Columbia were described by these healthcare professionals. Each conflict was analyzed according to three themes: the practice context, the ethical principles in conflict, and how the conflict was experienced by the nurse subject. The majority of ethical conflicts (75%) concerned disagreement with the quality of medical care the patient was receiving. The principles most often in conflict were beneficence and nonmaleficence. Most conflicts were experienced as dilemmas (two or more principles that seem to apply but support mutually inconsistent courses of action).

Ethical issues in the development and use of guidelines for clinical practice.

In order to serve the purposes expected of them, practice guidelines must be more than summaries of available research; they must also challenge the values that are implicit in the way practice questions have been framed and outcomes have been chosen. The IOM has defined desirable attributes of practice guidelines, focused on the characteristics of measurement and implementation. It is also desirable for guidelines to meet certain ethical criteria.

The ethics of leadership in pharmacy.

The pharmacy profession's responsibility to provide ethical leadership to its members is explained, and areas where pharmacy should take a leadership role are described. Changes taking place in health care offer many opportunities for pharmacy in its transformation into a fully clinical discipline. The profession needs to address the ethical issues that will affect it as part of this revolution. The role pharmacy is taking to eliminate medication misadventuring will be a test case for the profession's ability to exert the leadership it must, as part of its new definition of itself. Pharmacy needs to define the structure, process, and outcomes necessary to improve its own practice to avoid drug misadventuring, with a clear set of practice and ethical standards, and engage medicine and nursing to adopt similar standards. Pharmacy should also take a leadership role in health care reform, working with other clinicians to ensure that the changes provide better outcomes for patients. Health care professionals are bound together by a common moral purpose: to act in the patient's best interest. Thus, each health profession is a moral community, which must determine and promote ethical behavior among its members. Pharmacy must practice ethical leadership: it must define and prove its contribution to patient outcomes, further develop legal and ethical standards, and examine its responsibilities for vulnerable patient groups such as children. It must work to overcome the traditional dominance of medicine; pharmacy, nursing, and medicine must come together in service of the patient and develop a cross-professional conception of ethics. Pharmacy also must participate in the broader debate about health care. Pharmacy has begun to take a leadership role among the health professions through its efforts to eliminate medication misadventuring. Additional leadership challenges for the profession are suggested.