Aimee Milliken

Nurse ethical awareness Understanding the nature of everyday practice

Much attention has been paid to the role of the nurse in recognizing and addressing ethical dilemmas. There has been less emphasis, however, on the issue of whether or not nurses understand the ethical nature of everyday practice. Awareness of the inherently ethical nature of practice is a component of nurse ethical sensitivity, which has been identified as a component of ethical decision-making. Ethical sensitivity is generally accepted as a necessary precursor to moral agency, in that recognition of the ethical content of practice is necessary before consistent action on behalf of patient interests can take place. This awareness is also compulsory in ensuring patient good by recognizing the unique interests and wishes of individuals, in line with an ethic of care. Scholarly and research literature are used to argue that bolstering ethical awareness and ensuring that nurses understand the ethical nature of the role are an obligation of the profession. Based on this line of reasoning, recommendations for education and practice, along with directions for future research, are suggested.

“It just took the pressure off”: The voices of Veterans’ family caregivers in a participant-directed program

ABSTRACT The Veteran-Directed Home and Community Based Services Program (VD-HCBS) operates using a participant-direction approach, allowing Veterans to self-direct services. Only a small body of literature has explored the impact of these programs on caregivers. This study aimed to explore the experiences of caregivers in VD-HCBS. Telephone focus groups and interviews were conducted with caregivers (n = 23; 52.2% spouses; 8.7% male). Conventional content analysis revealed five categories: Coming home and staying home; Taking the pressure off; Providing security; Giving us time as a couple; and Importance of choice. Stories highlighted sources of stress and mechanisms behind stress relief and support.

Educating Nurses for Ethical Practice in Contemporary Health Care Environments

Because health care professions exist to provide a good for society, ethical questions are inherently part of them. Such professions and their members can be assessed based on how effective they are in developing knowledge and enacting practices that further the health and well-being of individuals and society. The complexity of contemporary health care environments makes it important to prepare clinicians who can anticipate, recognize, and address problems that arise in practice or that prevent a profession from fulfilling its service goals and obligations. Different health care professions have evolved distinct perspectives about appropriate goals for, and the purposes of, their clinicians, even when the goal of improving health and well-being for society is shared across professions. While medicine and nursing goals are shared in principle, they differ in the particulars. Given the centrality to nursing of ethical questions, the profession has a collective responsibility to help clinicians at all levels of practice become ethically savvy and to reinforce their moral agency as needed. Both knowledge of nursing ethics and knowledge of the interdisciplinary field of bioethics are critical to nursing work.

Nurse ethical sensitivity An integrative review

Background: Ethical sensitivity has been identified as a foundational component of ethical action. Diminished or absent ethical sensitivity can result in ethically incongruent care, which is inconsistent with the professional obligations of nursing. As such, assessing ethical sensitivity is imperative in order to design interventions to facilitate ethical practice and to ensure nurses recognize the nature and extent of professional ethical obligations. Aim: To review and critique the state of the science of nurse ethical sensitivity and to synthesize findings across studies. Research design: Whittemore and Knafl’s revised framework for integrative reviews guided the analysis. Research context and data sources: A comprehensive, computer-assisted search of literature published in Cumulative Index of Nursing and Allied Health Literature and PubMed was performed. A systematic approach was used to extract, reduce, and synthesize the data. Findings: Four major conceptualizations of ethical sensitivity emerged from the literature. A sample of 25 reports met inclusion criteria, including 17 empirical reports and 8 theoretical reports. Discussion: Despite the existence of a concept analysis and a validated tool, ethical sensitivity remains a highly theoretical concept with multiple, and at times competing, conceptualizations. Ethical sensitivity has been assessed extensively in the context of ethical dilemmas; however, little attention has been paid to the way the concept operates in day-to-day practice. Conclusion: Future research should focus on better ways to operationalize and assess the concept, with particular attention to nurse awareness of the ethical content of everyday practice.

“It’s Changed Everything”: Voices of Veterans in the Veteran-Directed Home and Community Based Services Program

ABSTRACT The purpose of this study was to understand the value and impact of the Veteran-Directed Home and Community Based Services program (VD-HCBS) on Veterans’ lives in their own voices. Focus groups and individual interviews by telephone were conducted to elicit participant perspectives on what was most meaningful, and what difference VD-HCBS made in their lives. Transcripts were analyzed using content analysis. The sample included 21 Veterans, with a mean age of 66±14, enrolled in VD-HCBS an average of 20.8 months. All were at risk of institutional placement based on their level of disability. Five major categories captured the information provided by participants: What a Difference Choice Makes; I’m a Person!; It’s a Home-Saver; Coming Back to Life; and Keeping Me Healthy & Safe. Participants described the program as life changing. This study is the first time that Veterans themselves have identified the ways in which VD-HCBS impacted their lives, uncovering the mechanisms underlying positive outcomes. These categories revealed new ways of understanding VD-HCBS as an innovative approach to meeting the person-centered needs of Veterans wishing to remain at home, while experiencing quality care and leading meaningful lives, areas identified as priorities for improving long term services and supports.

“I’m just trying to cope for both of us”: Challenges and supports of family caregivers in participant-directed programs

ABSTRACT Recently, national attention has focused on the needs of family caregivers providing complex chronic care, noting the necessity to better understand the scope of challenges they encounter. Although a robust body of literature exists about the scope of family caregiving, little is known specifically about the experiences and perspectives of family caregivers who support participant directed (PD) participants, particularly across the caregiving trajectory. Therefore, the aim of this qualitative descriptive study was to describe what family caregivers of individuals with developmental disabilities, physical disabilities, aging, or chronic health conditions identify as the challenges they experience as complex, and their perceptions of the effectiveness and gaps in family support resources in PD. Semi-structured interviews were audio-recorded with a purposive sample of caregivers. Transcribed interviews were analyzed using conventional content analysis. Fifty-four caregivers of individuals with a range of disabilities participated (age 34–78, M 59.9 ± 8.8; male 19%; spouse 17%, parent 61%). Six categories emerged from the analysis: contextualizing complexity, complexity in transitions, coping with complexity: advocacy & isolation, supportive support, unsupportive support, and systems challenges. Caregivers emphasized the interplay between unpredictability, transitions, and complexity and the interaction between the person receiving support, the caregiver’s own situation, and the environment. Findings highlight the need, and provide a guide, for family assessment and for tailoring interventions matched to the profiles and self-identified challenges of families living with disability. Social workers can learn what families see as complex and what support broker behaviors families find helpful, and which not.

Subjective from the start: A critique of transformative criticism

Objectivity has been traditionally established as an aim of science; however, its feasibility and desirability have been repeatedly called into question. In this article, I provide a brief overview of the historical context surrounding the concept of objectivity in science. I then examine Helen Longinos theory of transformative criticism as an example of an attempt to secure scientific objectivity through the social nature of the scientific process. Possible objections to this critique are discussed, and ultimately, I argue that her account falls short in securing scientific objectivity. I briefly discuss objectivity and its relationship to human sciences such as nursing. I conclude by arguing that achieving complete objectivity in science is neither possible nor desirable.

Toward Everyday Ethics: Strategies for Shifting Perspectives

Jane, a nurse in the cardiac intensive care unit, is caring for a patient during an overnight shift when the patient’s blood pressure starts to drop. The patient’s mean arterial pressures are consistently low and the hypotension does not improve with fluid resuscitation. The resident on call makes the decision to start a norepinephrine drip; however, the patient only has peripheral intravenous (IV) lines. Jane lets the resident know that the patient will need a central line as per hospital policy. The resident tells Jane that he does not want to wake up the attending physician and that infusing the norepinephrine peripherally is an acceptable course of action. Jane is not sure how to proceed but does not discuss the issue further with the resident. She is uncomfortable with his decision and is concerned that infusing the norepinephrine through a peripheral IV puts her patient at risk for a dangerous infiltration and extravasation. She knows that a central line would be safer and that her hospital’s policy requires it; however, Jane is unsure whether calling the attending physician herself would be appropriate. Not wanting to cause trouble with the resident, Jane decides to let it go and continues the norepinephrine infusion through the peripheral IV for the rest of the night.

Time to Breathe

As health care providers, we become all too familiar with suppressing our emotions, putting on a brave face, and going through the necessary motions at the bedside. We power through these emotionally charged scenarios day after day, patient after patient. We try to remain serene, to appear calm, and to exude confidence, competence, and professionalism. We deliver life-altering news to devastated families; we sit at dying patients’ bedsides and hold their hands as their hearts stop; we deplete ourselves physically and emotionally when a healthy patient takes a turn for the worse. We skillfully manage the natural process of another persons body decompensating while we hold back our tears, sadness, or sense of defeat. And then we take a deep breath and walk into the next room to see the next patient. We betray our inner turmoil by putting on a smiling face, by focusing on facts, by completing necessary tasks.

Duty, Distress, and Organ Donation

A man of twenty-two is admitted to an intensive care unit (ICU)after intentionally overdosing on Tylenol. The nurse asks the intensivist on call if someone from the local organ procurement organization should be called in to speak to the family, given a worsening clinical picture and the likelihood that the patient will progress to brain death. The patients condition is such that multiple organs, including his heart and lungs, could be donated. The intensivist instructs the nurse not to call, as he wishes to have an end-of-life discussion with the parents. He believes that the parents should know that death is imminent and that further interventions will not save their son. He argues that introducing the OPO at this point will cause the family more distress. He wants the parents to be able to give their son a peaceful death without additional stressors. What are the broader implications of not calling the OPO at this juncture? Does the nurse involved have an ethical obligation to override the intensivists instructions by calling the OPO? Should the fact that multiple healthy organs could be harvested from this patients body have any bearing on the decision to call the OPO?