Bernie Pauly

Nurses’ perceptions of and responses to morally distressing situations:

Research on moral distress has paid limited attention to nurses’ responses and actions. In a survey of nurses’ perceptions of moral distress and ethical climate, 292 nurses answered three open-ended questions about situations that they considered morally distressing. Participants identified a range of situations as morally distressing, including witnessing unnecessary suffering, being forced to provide care that compromised values, and negative judgments about patients. They linked these situations to contextual constraints such as workload and described responses, including feeling incompetent and distancing themselves from patients. Participants described considerable effort to effect change, calling into question the utility of defining moral distress as an “inability to act due to institutional constraints” or a “failure to pursue a right course of action.” Various understandings of moral distress operated, and action was integral to their responses. The findings suggest further conceptual work on moral distress and effort to support system-level change.

Take Me to My Leader: The Importance of Ethical Leadership Among Formal Nurse Leaders

Although ethical leadership by formal nurse leaders is critical to enhancing ethical health-care practice, research has shown that many nurses feel unsupported by their leaders. In this article, we consider the limited attention directed toward ethical leadership of formal nurse leaders and how our own research on ethical nurse leadership compares to other research in this field. In searching Nursing Ethics since its inception 20 years ago, we found only a dozen articles that directly addressed this topic. We then reviewed nurses’ professional codes of ethics in Canada and found significant retractions of ethical guidelines for formal nurse leaders’ ethical responsibilities over the past decade. We began to seek explanations of why this is so and offer some recommendations for the study and enhancement of ethics for formal nurse leadership.

Searching for ethical leadership in nursing

Background: Attention to ethical leadership in nursing has diminished over the past several decades. Objectives: The aim of our study was to investigate how frontline nurses and formal nurse leaders envision ethical nursing leadership. Research design: Meta-ethnography was used to guide our analysis and synthesis of four studies that explored the notion of ethical nursing leadership. Participants and research context: These four original studies were conducted from 1999-2008 in Canada with 601 participants. Ethical considerations: Ethical approval from the original studies covered future analysis. Findings: Using the analytic strategy of lines-of-argument, we found that 1) ethical nursing leadership must be responsive to practitioners and to the contextual system in which they and formal nurse leaders work, and 2) ethical nursing leadership requires receiving and providing support to increase the capacity to practice and discuss ethics in the day-to-day. Discussion and conclusion: Formal nurse leaders play a critical, yet often neglected role, in providing ethical leadership and supporting ethical nursing practice at the point of patient care.

Death Is a Social Justice Issue: Perspectives on Equity-Informed Palliative Care.

All too often, palliative care services are not responsive to the needs of those who are doubly vulnerable, being that they are both in need of palliative care services and experiencing deficits in the social determinants of health that result in complex, intersecting health and social concerns. In this article, we argue for a reorientation of palliative care to explicitly integrate the premises of health equity. We articulate the philosophical, theoretical, and empirical scaffolding required for equity-informed palliative care and draw on a current study to illustrate such an approach to the care of people who experience structural vulnerabilities.

Approaches to evaluation of homelessness interventions

Purpose – The purpose of this paper is to provide rationale, methodological guidance and clarity in the use of case study designs and theory driven approaches to evaluation of interventions to end homelessness. Design/methodology/approach – Using an evaluation of a transitional shelter program aiming to support permanent exits from homelessness as an example, the authors show how case study designs and theory driven evaluation is well suited to the study of the effectiveness of homelessness interventions within the broader socio-political and economic context in which they are being implemented. Findings – Taking account of the context as part of program evaluation and research on homelessness interventions moves away from blaming programs and individuals for systemic failures to better understanding of how the context influences successes and failures. Case study designs are particularly useful for studying implementation and the context which influences program outcomes. Theory driven evaluations and th...

Homelessness Outcome Reporting Normative Framework Systems-Level Evaluation of Progress in Ending Homelessness

Homelessness is a serious and growing issue. Evaluations of systemic-level changes are needed to determine progress in reducing or ending homelessness. The report card methodology is one means of systems-level assessment. Rather than solely establishing an enumeration, homelessness report cards can capture pertinent information about structural determinants of homelessness. This information can inform the development of evidence-based strategies aimed at ending (rather than managing) homelessness. To aid in the development of homelessness report card creation, a systems-level Homelessness Outcome Reporting Normative Framework (the HORN Framework) was developed. This article provides an overview of the framework and its application.

Harm reduction in name, but not substance: a comparative analysis of current Canadian provincial and territorial policy frameworks

BackgroundIn Canada, funding, administration, and delivery of health services—including those targeting people who use drugs—are primarily the responsibility of the provinces and territories. Access to harm reduction services varies across jurisdictions, possibly reflecting differences in provincial and territorial policy commitments. We examined the quality of current provincial and territorial harm reduction policies in Canada, relative to how well official documents reflect internationally recognized principles and attributes of a harm reduction approach.MethodsWe employed an iterative search and screening process to generate a corpus of 54 provincial and territorial harm reduction policy documents that were current to the end of 2015. Documents were content-analyzed using a deductive coding framework comprised of 17 indicators that assessed the quality of policies relative to how well they described key population and program aspects of a harm reduction approach.ResultsOnly two jurisdictions had current provincial-level, stand-alone harm reduction policies; all other documents were focused on either substance use, addiction and/or mental health, or sexually transmitted and/or blood-borne infections. Policies rarely named specific harm reduction interventions and more frequently referred to generic harm reduction programs or services. Only one document met all 17 indicators. Very few documents acknowledged that stigma and discrimination are issues faced by people who use drugs, that not all substance use is problematic, or that people who use drugs are legitimate participants in policymaking. A minority of documents recognized that abstaining from substance use is not required to receive services. Just over a quarter addressed the risk of drug overdose, and even fewer acknowledged the need to apply harm reduction approaches to an array of drugs and modes of use.ConclusionsCurrent provincial and territorial policies offer few robust characterizations of harm reduction or go beyond rhetorical or generic support for the approach. By endorsing harm reduction in name, but not in substance, provincial and territorial policies may communicate to diverse stakeholders a general lack of support for key aspects of the approach, potentially challenging efforts to expand harm reduction services.

Factors associated with public injection and nonfatal overdose among people who inject drugs in street-based settings

Abstract Background: In 2016, BC Canada declared a public health emergency in response to increasing illicit drug overdose deaths. Previous research has shown that adverse social conditions including unstable housing and insufficient harm reduction services can exacerbate public injection and overdoses. Methods: Cross-sectional interview data from Victoria (2008–2015) and Vancouver (2008–2012), BC (n = 548) were analysed using multivariate logistic regression models to assess differences in risks and harms for people 19+ who inject drugs in street-based settings. Results: Living in Victoria (OR: 5.55, 95%CI: 3.44–8.95; p < 0.001), having unstable housing (OR: 4.24, 95%CI: 2.75–6.54; p < 0.001), injecting daily (OR: 2.24, 95%CI: 1.40–3.58; p < 0.001), sharing needles (OR: 3.00, 95%CI: 1.22–7.38; p < 0.05), and sexual minority status (OR: 2.14, 95%CI: 1.06–4.34; p < 0.05) were significantly associated with increased risk of public injection. Being older (OR: 0.96, 95%CI: 0.94–0.99; p < 0.01), identifying as Indigenous (OR: 0.58, 95%CI: 0.34–0.98; p < 0.05) and later survey year (OR: 0.83, 95%CI: 0.74–0.93; p < 0.001) were associated with a decreased risk of public injection. Living in Victoria (OR: 2.21, 95%CI: 1.30–3.75; p < 0.01) was significantly associated with higher risk of overdose and being older (OR: 0.96, 95%CI: 0.94–0.99; p < 0.01) was associated with decreased risk. Conclusions: Mitigating risk environments for public injection and overdose requires attention to micro- and macro-level factors. Overall findings indicate that implementation of a supervised injection facility in Victoria would likely reduce public injection and overdoses.

Situational Analysis for Complex Systems: Methodological Development in Public Health Research

Public health systems have suffered infrastructure losses worldwide. Strengthening public health systems requires not only good policies and programs, but also development of new research methodologies to support public health systems renewal. Our research team considers public health systems to be complex adaptive systems and as such new methods are necessary to generate knowledge about the process of implementing public health programs and services. Within our program of research, we have employed situational analysis as a method for studying complex adaptive systems in four distinct research studies on public health program implementation. The purpose of this paper is to demonstrate the use of situational analysis as a method for studying complex systems and highlight the need for further methodological development.