Katherine Brown-Saltzman

Expanding Nurses’ Participation in Ethics: an empirical examination of ethical activism and ethical assertiveness

This research project investigated the extent to which nurses engage in two important kinds of ethical behaviours: ethical activism (where they try to make hospitals more receptive to nurses’ participation in ethics deliberations) and ethical assertiveness (where they participate in ethics deliberations even when not formally invited). This research probed not only the extent to which nurses engage in these ethical behaviours but also whether this is influenced by professional, training and organizational factors. A random sample of 165 nurses from three major hospitals in Los Angeles provided the data. Regression analyses indicate that both ethical activism and ethical assertiveness are strongly influenced by nurses’ perceptions of the receptivity of hospitals to their inclusion in ethics deliberations. In addition, nurses’ education in ethics is a significant predictor of ethical activism. The findings have important implications for the content of nurses’ ethics training as well as for expanding the boundaries of nurses’ participation in ethics deliberations. The authors define ethics deliberations as specific meetings of a number of people to discuss an ethical issue, such as one regarding the care of a patient.

The Nature of Ethical Conflicts and the Meaning of Moral Community in Oncology Practice

PURPOSE/OBJECTIVES To explore ethical conflicts in oncology practice and the nature of healthcare contexts in which ethical conflicts can be averted or mitigated. RESEARCH APPROACH Ethnography. SETTING Medical centers and community hospitals with inpatient and outpatient oncology units in southern California and Minnesota. PARTICIPANTS 30 oncology nurses, 6 ethicists, 4 nurse administrators, and 2 oncologists. METHODOLOGIC APPROACH 30 nurses participated in six focus groups that were conducted using a semistructured interview guide. Twelve key informants were individually interviewed. Coding, sorting, and constant comparison were used to reveal themes. FINDINGS Most ethical conflicts pertained to complex end-of-life situations. Three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling torn between competing obligations, and the silencing of different moral perspectives. Moral communities were characterized by respectful team relationships, timely communication, ethics-minded leadership, readily available ethics resources, and provider awareness and willingness to use ethics resources. CONCLUSIONS Moral disagreements are expected to occur in complex clinical practice. However, when they progress to ethical conflicts, care becomes more complicated and often places seriously ill patients at the epicenter. INTERPRETATION Practice environments as moral communities could foster comfortable dialogue about moral differences and prevent or mitigate ethical conflicts and the moral distress that frequently follows.

A Culture of Avoidance: Voices From Inside Ethically Difficult Clinical Situations

BACKGROUND Healthcare providers experience many ethical challenges while caring for and making treatment decisions with patients and their families. OBJECTIVES The purpose of this ethnographic study was to examine the challenges and circumstances that surround ethically difficult situations in oncology practice. METHODS The authors conducted six focus groups with 30 oncology nurses in the United States and interviewed 12 key informants, such as clinical ethicists, oncologists, and nurse administrators. FINDINGS The authors found that many healthcare providers remain silent about ethical concerns until a precipitating crisis occurs and ethical questions can no longer be avoided. Patients, families, nurses, and physicians tended to delay or defer conversations about prognosis and end-of-life treatment options. Individual, interactional, and system-level factors perpetuated the culture of avoidance. These included the intellectual and emotional toll of addressing ethics, differences in moral perspectives, fear of harming relationships, lack of continuity in care, emphasis on efficiency, and lack of shared decision making. This information is critical for any proactive and system-level effort aimed at mitigating ethical conflicts and their frequent companions-moral distress and burnout.

SUPPORT: An Evidence-Based Model for Leaders Addressing Moral Distress.

OBJECTIVE: The aim of this study is to explore nurse leaders’ experiences working in ethically difficult situations and helping nurses cope with moral distress. BACKGROUND: Moral distress is associated with ethically complex situations where nurses feel voiceless and powerless. Moral distress can lead to disengagement, burnout, and decreased quality of care. METHODS: The critical incident technique was used to collect descriptions of ethically complex situations from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and subsequently counted. RESULTS: Participants noted affective, behavioral, cognitive, physical, and relational signs of moral distress. System-level factors along with team conflict and different perspectives were perceived to increase the probability of ethical conflicts. Key actions to address moral distress included acknowledging its presence, creating a culture of care, and increasing nurses’ resilience to difficult circumstances through education, support, and collaboration. CONCLUSIONS: On the basis of study findings, we created the SUPPORT model as an action guide for addressing moral distress.

Making the Call: A Proactive Ethics Framework

This manuscript proposes a proactive framework for preventing or mitigating disruptive ethical conflicts that often result from delayed or avoided conversations about the ethics of care. Four components of the framework are explained and illustrated with evidenced-based actions. Clinical implications of adopting a prevention-based, system-wide ethics framework are discussed. While some aspects of ethically-difficult situations are unique, system patterns allow some issues to occur repeatedly—often with lingering effects such as healthcare providers’ disengagement and moral distress (McAndrew et al. Journal of Trauma Nursing 18(4):221–230, 2011), compromised inter-professional relationships (Rosenstein and O’Daniel American Journal of Nursing, 105(1):54–64, 2005), weakened ethical climates (Pauly et al. HEC Forum 24:1–11, 2012), and patient safety concerns (Cimiotti et al. American Journal of Infection Control 40:486–490, 2012). This work offers healthcare providers and clinical ethicists a framework for developing a comprehensive set of proactive, ethics-specific, and evidence-based strategies for mitigating ethical conflicts. Furthermore, the framework aims to encourage innovative research and novel ways of collaborating to reduce such conflicts and the moral distress that often results.

Predicting Levels of Policy Advocacy Engagement Among Acute-Care Health Professionals

This study aims to describe the factors that predict health professionals’ engagement in policy advocacy. The researchers used a cross-sectional research design with a sample of 97 nurses, 94 social workers, and 104 medical residents from eight hospitals in Los Angeles. Bivariate correlations explored whether seven predictor scales were associated with health professionals’ policy advocacy engagement and revealed that five of the eight factors were significantly associated with it (p < .05). The factors include patient advocacy engagement, eagerness, skills, tangible support, and organizational receptivity. Regression analysis examined whether the seven scales, when controlling for sociodemographic variables and hospital site, predicted levels of policy advocacy engagement. Results revealed that patient advocacy engagement (p < .001), eagerness (p < .001), skills (p < .01), tangible support (p < .01), perceived effectiveness (p < .05), and organizational receptivity (p < .05) all predicted health professional’s policy advocacy engagement. Ethical commitment did not predict policy advocacy engagement. The model explained 36% of the variance in policy advocacy engagement. Limitations of the study and its implications for future research, practice, and policy are discussed.

Physicians’ Perspectives on Ethically Challenging Situations: Early Identification and Action

Background: Limited information on risk factors for ethically difficult clinical situations exists. Identifying common factors in these situations could encourage a more proactive, system-wide approach to ethical issues, which could mitigate patient and family suffering, providers’ moral stress, and costly ethical conflicts. Methods: Quantitative and qualitative data analyses were performed on physician responses to an online survey that queried physician perceptions about ethically complex situations in a large academic medical center and community hospital. Results: Representing 30 specialties, 114 physicians responded. The most frequently encountered situation was working with patients who lacked capacity for decision making. End-of-life treatment decisions and family adamancy were ranked as the most intense situations. Interactional risk factors such as different moral perspectives and poor communication were most prominent (53.9%); patient and family risk factors were also described (33%). Physicians identified early and frequent communication with seriously ill patients and their families as the primary protection against ethical conflict. Ethics skill-building, good teamwork, and creating an ethics-minded culture were also featured as important preventive measures. Pressure from others to take morally uncomfortable action was most often cited as a source of moral stress. The pressure of limited time to address ethical issues was also frequently mentioned. These pressures could progress to ethical conflicts, which often compounded moral stress. A majority of physicians reported willingness to work with nurses on ethically difficult situations. Conclusions: Physicians are very aware of ethical complexities in their clinical practice and take their moral responsibilities very seriously. Communicating effectively with patients, families, and other health care team members and advocating for adequate resources, including ethics resources, are important avenues to mitigate ethical conflicts.

Avenues of action in ethically complex situations: a critical incident study.

OBJECTIVES: The aims of this study were to explore nurse leaders’ experiences with ethically difficult situations, perceptions about risk factors, and specific actions for ethical conflicts. BACKGROUND: Research indicates that nurses are reluctant to bring ethical concerns to nurse leaders for fear of creating trouble, and yet, nurse leaders are key figures in supporting ethics-minded clinicians and cultures. METHODS: The critical incident technique was used to collect descriptions from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and counted. RESULTS: End-of-life situations accounted for the majority of incidents. Most situations had 3 to 4 ethical issues. Healthcare provider and system-level factors were perceived to increase the likelihood of ethical conflicts more often than family and patient factors. Respondents were more likely to identify leader actions that address specific situations rather than specify system-level actions addressing root causes of conflicts. CONCLUSIONS: Findings can be used to help leaders create ethics competencies, policies, and education.

The Existential Question in Palliative Sedation: Reply to Putman et al.

To the Editor: Putman et al. provide an important contribution to the palliative sedation literature in evidencing that physicians see a critical difference between intending unconsciousness andmerely tolerating it as a foreseen, although unintended consequence. They further examine whether physicians believe that a patient has the right to decide to hasten one’s death, a doctor’s role therein, and the topic of sedating to unconsciousness for existential suffering. On the basis of this well-powered study ofU.S. physicians, the authors claim that ‘‘two of three physicians opposed sedation to unconsciousness for existential suffering.’’ Although their contributions should serve to inform the dialogue regarding the scope and practice of palliative sedation, the implications tobederivedaboutpalliative sedation for existential suffering are limited. We identify two areas left unaddressed, with the goal of recommending further attention be directed toward this ‘‘existential question.’’ The authors surveyed physicians’ perceptions of palliative sedation for existential suffering in two manners. Initially, they provided a clinical vignette to garner beliefs in the setting of a hypothetical narrative. Later in the survey, respondents were asked to indicate whether they agreed or disagreed with the statement ‘‘doctors should sometimes treat the psychological and spiritual suffering of terminally ill patients by sedating the patient to unconsciousness.’’ This statement does not expressly indicate whether physicians would be intending unconsciousness or simply sedating to a point where the psychological and spiritual suffering is managed, although

Dissenting on the Matter of Assent

involve complex health-related concepts, which are often unfamiliar to patients, they may require extensive decomposition into several simpler questions that would allow the patient to fully understand the issue at hand. The result of this requirement could yield an unfeasibly long scanning session that would tax even the attention span of a healthy participant. While these technical limitations may be resolved with future improvements in noninvasive imaging technologies, integrating the mental imagery method into medical practice by way of assessing decision-making capacity remains conceptually problematic. As any healthy individual’s ability to provide informed consent is contingent upon the presumption of capacity, a central epistemological question is how we can ever know that a given DOC patient does, in fact, have some residual dimension of decisionmaking capacity intact. Though Bendtsen suggests medical decision making on behalf of children may serve as a possible solution to this question, it is not clear that this would adequately address the issue of capacity assessment in DOC patients. For one, DOC patients exhibit no behavioral markers of residual cognitive function. Unlike the case of children, where modest levels of cognitive function can be inferred, DOC patients reveal no such information. Thus, starting from the initial point of successful responses to the mental imagery tasks, investigators must build a model of the patient’s residual cognitive profile from the ground up. Moreover, as Bendtsen notes, identifying capacity in DOC patients with our imaging method is complicated by several other obstacles: Patients are unable to initiate their own questions, and psychiatric problems secondary to neurological conditions are difficult to rule out. One solution to this broadly epistemological problem may be to more precisely define what decision-making capacity amounts to in these cases, and determine how it might be operationalized in ways that are detectable through fMRI and EEG. The first step may be to take the complex set of faculties we refer to as “capacity” and describe them in terms of decomposed cognitive functions. These might include, for example, whether the patient can localize himor herself in space and time, has any memory or knowledge of basic facts about the world, has any reasoning skills, or has retained the ability to form new memories based on experiences that occurred after the initial injury. We would then need to consider how this information could be synthesized to provide a reliable and ethically responsible overall assessment of the more complex dimensions of decision-making capacity in this patient group. If these components can be operationalized for binary assessment successfully, the mental imagery method may, indeed, be a satisfactory tool for this specific application. While concrete resolutions to these practical and philosophical problems have yet to be worked out, we remain optimistic that solutions to these issues will emerge in the near future. Notwithstanding these obstacles, Bendtsen’s article successfully raises a number of important questions related to our work, including how we assess capacity in DOC patients and whether they can be included in the clinical decision-making process aided by neuroimaging BCIs. We are hopeful that, with further technical developments, these methods will yield effective and economically sustainable results, thereby mitigating many of the technical limitations discussed here. More importantly, we anticipate that in the near future a conceptual framework will be developed to accommodate the epistemological and ethical challenges that our work has generated in this area.