David Kenneth Wright

Creating a Healthy Workplace for New-Generation Nurses

PURPOSE To examine dimensions of the psychosocial work environment that influence the psychological health of new-generation nurses. BACKGROUND While much work has been done concerning the health of nurses in general, research on the relationship between the nursing work environment and the psychological well-being of new-generation nurses at the start of their careers is limited. DESIGN A correlational descriptive design was used for this quantitative study. Survey data were collected from new nurses (N=309) whose names were obtained from a provincial licensing registry in Quebec, Canada. FINDINGS Among new nurses, 43.4% stated that they have a high level of psychological distress. These nurses were significantly more likely to perceive an imbalance between effort expended on the job and rewards received, low decisional latitude, high psychological demands, high job strain, as well as low social support from colleagues and superiors (p < or = 0.05). CONCLUSIONS Understanding the relationship between the work environment and health as experienced by new-generation nurses is imperative for creating interventions to successfully recruit and retain these young nurses. CLINICAL RELEVANCE Generation Y nurses in Quebec, faced with high levels of psychological distress because of their exposure to difficult nursing work environments, might leave the profession thereby exacerbating an already salient nursing shortage.

End-of-Life Delirium: Issues Regarding Recognition, Optimal Management, and the Role of Sedation in the Dying Phase

CONTEXT In end-of-life care, delirium is often not recognized and poses unique management challenges, especially in the case of refractory delirium in the terminal phase. OBJECTIVES To review delirium in the terminal phase context, specifically in relation to recognition issues; the decision-making processes and management strategies regarding its reversibility; the potential refractoriness of delirium to symptomatic treatment; and the role of sedation in refractory delirium. METHODS We combined multidisciplinary input from delirium researchers and knowledge users at an international delirium study planning meeting and relevant electronic database literature searches (Ovid Medline, Embase, PsycINFO, and CINAHL) to inform this narrative review. RESULTS The overall management strategy for delirium at the end of life is directed by the patients prognosis in association with the patients goals of care. As symptoms of delirium are often refractory in the terminal phase, especially in the case of agitated delirium, the judicious use of palliative sedation is frequently required. However, there remains a lack of high-level evidence for the management of delirium in the terminal phase, including the role of antipsychotics and optimal sedation strategies. For the family and health-care staff, clear communication, education, and emotional support are vital components to assist with decision making and direct the treatment care plan. CONCLUSION Further research on the effectiveness of delirium management strategies in the terminal phase for patients and their families is required. Further validation of assessment tools for diagnostic screening and severity measurement is needed in this patient population.

Relational and embodied knowing: Nursing ethics within the interprofessional team

In this article we attempt to situate nursing within the interprofessional care team with respect to processes of ethical practice and ethical decision making. After briefly reviewing the concept of interprofessionalism, the idea of a nursing ethic as ‘unique’ within the context of an interprofessional team will be explored. We suggest that nursing’s distinct perspective on the moral matters of health care stem not from any privileged vantage point but rather from knowledge developed through the daily activities of nursing practice. Because of their position vis-à-vis patients and families in everyday clinical care, nurses cultivate ethical knowledge of at least two forms: (1) relational knowledge; and (2) embodied knowledge. Through the integration of these forms of knowledge, nurses develop a unique moral perspective and can make a meaningful contribution to the realm of ethics in interprofessional care.

Treating an Established Episode of Delirium in Palliative Care: Expert Opinion and Review of the Current Evidence Base With Recommendations for Future Development

CONTEXT Delirium is a highly prevalent complication in patients in palliative care settings, especially in the end-of-life context. OBJECTIVES To review the current evidence base for treating episodes of delirium in palliative care settings and propose a framework for future development. METHODS We combined multidisciplinary input from delirium researchers and other purposely selected stakeholders at an international delirium study planning meeting. This was supplemented by a literature search of multiple databases and relevant reference lists to identify studies regarding therapeutic interventions for delirium. RESULTS The context of delirium management in palliative care is highly variable. The standard management of a delirium episode includes the investigation of precipitating and aggravating factors followed by symptomatic treatment with drug therapy. However, the intensity of this management depends on illness trajectory and goals of care in addition to the local availability of both investigative modalities and therapeutic interventions. Pharmacologically, haloperidol remains the practice standard by consensus for symptomatic control. Dosing schedules are derived from expert opinion and various clinical practice guidelines as evidence-based data from palliative care settings are limited. The commonly used pharmacologic interventions for delirium in this population warrant evaluation in clinical trials to examine dosing and titration regimens, different routes of administration, and safety and efficacy compared with placebo. CONCLUSION Delirium treatment is multidimensional and includes the identification of precipitating and aggravating factors. For symptomatic management, haloperidol remains the practice standard. Further high-quality collaborative research investigating the appropriate treatment of this complex syndrome is needed.

A Relational Ethical Approach to End-of-Life Delirium

Delirium is a condition of acute onset and fluctuating course in which a persons level of consciousness and cognition become disturbed. Delirium is a common and distressing phenomenon in end-of-life care, yet it is underrecognized and undertreated. In this article, we review qualitative descriptions of the delirium experience in end-of-life care, found through a systematic search of academic databases, to generate insight into the intersubjective nature of the delirium experience. Our analysis of retrieved studies advances an understanding of the relational ethical dimensions of this phenomenon, that is, how delirium is lived by patients, families, and health care providers and how it affects the relationships and values at stake. We propose three themes that explain the distressing nature of delirium in palliative care: 1) experiences of relational tension; 2) challenges in recognizing the delirious person; and 3) struggles to interpret the meaning of delirious behaviors. By approaching end-of-life delirium from a perspective of relational ethics, attention is focused on the implications for the therapeutic relationship with patients and families when delirium becomes part of the dying trajectory.

Relational dimensions of a positive integration experience for new mental health nurses.

This study investigated the key aspects of a successful integration experience into mental health nursing from the perspectives of new nurses working in a psychiatric institution. Analysis of 10 semistructured interviews revealed that the relational atmosphere in which new nurses find themselves is determinant of their satisfaction with their integration experience. Quality relational connections with patients constitute the primary motivation of new nurses in choosing a career in mental health. At the same time, quality relational connections between and among team members sustain such motivation. Conversely, a negative relational atmosphere sets the stage for new nurses to experience disillusionment and despair.

Delirium as letting go: An ethnographic analysis of hospice care and family moral experience:

Background: Delirium is extremely common in dying patients and appears to be a major threat to the family’s moral experience of a good death in end-of-life care. Aim: To illustrate one of the ways in which hospice caregivers conceptualize end-of-life delirium and the significance of this conceptualization for the relationships that they form with patients’ families in the hospice setting. Design: Ethnography. Setting/participants: Ethnographic fieldwork was conducted at a nine-bed, freestanding residential hospice, located in a suburban community of Eastern Canada. Data collection methods included 15 months of participant observation, 28 semi-structured audio-recorded interviews with hospice caregivers, and document analysis. Results: Hospice caregivers draw on a culturally established framework of normal dying to help families come to terms with clinical end-of-life phenomena, including delirium. By offering explanations about delirium as a natural feature of the dying process, hospice caregivers strive to protect for families the integrity of the good death ideal. Conclusion: Within hospice culture, there is usefulness to deemphasizing delirium as a pathological neuropsychiatric complication, in favor of acknowledging delirious changes as signs of normal dying. This has implications for how we understand the role of nurses and other caregivers with respect to delirium assessment and care, which to date has focused largely on practices of screening and management.

Toward better care of delirious patients at the end of life: a pilot study of an interprofessional educational intervention.

Symptom distress with end-of-life delirium (EOLD) is complex and multidimensional, and interprofessional (IP) teams require knowledge and skill to effectively care for these patients and their families. The purpose of this pilot study was to test an educational intervention about EOLD for IP teams at a long-term care facility and a hospice. The intervention included a comprehensive self-learning module (SLM) on EOLD and IP teamwork; a modified McMaster–Ottawa team objective structured clinical encounter (TOSCE) and a didactic “theory burst” on the principles of delirium assessment, diagnosis and management. Evaluation tools completed by participants included the interprofessional collaborative competencies attainment survey (ICCAS) and the W(e) Learn. Two groups at each site participated in 1-hour sessions, repeated 2 weeks later. Only one group from each site received the SLM after the first session. Researchers scored EOLD knowledge and IP team functioning in both sessions. Results suggest that the intervention improved EOLD knowledge and perceptions of IP competence and supports the value of the TOSCE as an IP teaching method. The module does not appear responsible for the changes. Future studies are required to evaluate the effectiveness of the individual components used in this study, and to tailor the intervention to individual care contexts.

Les interventions infirmières estimées bénéfiques par les adolescents à risque de suicide

Adolescents at suicide risk: nursing care they consider helpful This qualitative study explores “helpful” nursing care from the perspective of adolescents at risk for suicide. While hospital-based nurses have a high level of direct and continuous contact with suicidal teens, little is known about the nursing care offered to this population. The purpose of this research is to explore the perceptions of suicidal adolescents regarding helpful nursing care during hospital treatment on a mental health unit. Nine patients, aged 15-18 years, participated in individualized, semi-structured interviews. Results affirm the importance of personalized, human caring interactions combined with nurse accompaniment across situations of daily living as well as during acute crisis, illness and suffering. The nurse’s role and contribution in creating a therapeutic milieu is described, and the impact of a health-promoting hospital environment on patient care and recovery is highlighted. Les interventions infirmières estimées bénéfiques par les adolescents à risque de suicide 207 Santé mentale 37, 2_Santé mentale 37, 2 13-03-04 08:57 Page207

Constructing physician-assisted dying: the politics of evidence from permissive jurisdictions in Carter v. Canada

Abstract Since the 1990s, there has been a growing global movement to legalise the controversial practice of physician-assisted dying (PAD). In the last twenty years, 13 jurisdictions have decriminalised or legalised PAD which, in turn, have produced new knowledge on the practice. The recent case of Carter v. Canada, which decriminalised PAD in Canada in 2015, provides us with an empirical opportunity to investigate how actors deployed and interpreted this new knowledge. We found that actors used expert evidence from permissive jurisdictions to construct different meanings of PAD as a legalised medical practice. The opponents constructed PAD as a practice accessed by patients who were suicidal, performed by uncaring physicians unskilled in end-of-life care, and loosely regulated through a fallible regime. The proponents used the evidence to construct PAD as a practice borne out of a patient’s rational choice, performed by caring physicians within an environment where end-of-life care had improved since legalisation, and tightly regulated through a regime where participants function as sentries overseeing each other’s actions. In the final analysis, we argue that the proponents’ success in this case contributed to the production and reproduction of a specific cultural script that renders PAD culturally appropriate.