Carol L. Pavlish

Somali Immigrant Women and the American Health Care System: Discordant Beliefs, Divergent Expectations, and Silent Worries

The civil war in Somalia resulted in massive resettlement of Somali refugees. The largest diaspora of Somali refugees in the United States currently reside in Minnesota. Partnering with three community organizations in 2007-8, we implemented the Community Connections and Collaboration Project to address health disparities that Somali refugees experienced. Specifically, we examined factors that influenced Somali womens health experiences. Utilizing a socio-ecological perspective and a social action research design, we conducted six community-based focus groups with 57 Somali women and interviewed 11 key informants including Somali healthcare professionals. Inductively coding, sorting and reducing data into categories, we analyzed each category for specific patterns. The categorical findings on healthcare experiences are reported here. We found that Somali womens health beliefs related closely to situational factors and contrasted sharply with the biological model that drives Western medicine. These discordant health beliefs resulted in divergent expectations regarding treatment and healthcare interactions. Experiencing unmet expectations, Somali women and their healthcare providers reported multiple frustrations which often diminished perceived quality of health care. Moreover, silent worries about mental health and reproductive decision making surfaced. To provide high quality, transcultural health care, providers must encourage patients to voice their own health explanations, expectations, and worries.

Screening Situations for Risk of Ethical Conflicts: A Pilot Study

BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

Moral Distress Research Agenda

In this chapter, we offer a framework based in socioecological theory to suggest a research agenda for moral distress. This perspective broadens the study of moral distress to understand not only the strategies that address moral distress but also ways that systems, teams, and individuals can intervene at earlier time points to prevent and/or mitigate moral distress. In so doing, we discuss sample studies and strategies within the context of moral obligations, agency, integrity, engagement, and support as well as the development of conditions that increase the risk for moral distress. We urge clinicians to study interventions that promote moral spaces for proactive, routine ethics consideration and dialogue among healthcare teams including patients and families. Investigating elements of strong moral communities is essential to a moral distress research agenda. We also examine individual and team-based risk reduction and treatment strategies including ideas for healing from moral distress. Finally, we recognize understudied topics such as the moral distress of patients, families, and surrogates. Research and quality improvement strategies to prevent, mitigate, and treat moral distress are critical to providing safe, effective health care and retaining clinicians who find meaning and satisfaction in their important work.

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BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

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BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

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BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

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BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

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BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

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BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.

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BACKGROUNDnEthical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes.nnnOBJECTIVESnTo examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients.nnnMETHODSnTwenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tools benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data.nnnRESULTSnOlder patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients suffering, unrealistic expectations, and providers own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations.nnnCONCLUSIONSnA phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.