Pamela J. Grace

A central unifying focus for the discipline: facilitating humanization, meaning, choice, quality of life, and healing in living and dying.

Nursing has a rich history of knowledge development, yet there remains ambiguity about what is a proper central unifying focus for the discipline. At this time in our history, it is imperative that we clearly define and articulate who we are and what we offer. Confusion about a central unifying focus is a significant problem for practice given the current healthcare environment and global problems affecting health and healing. The authors propose a central unifying focus for the discipline: facilitating humanization, meaning, choice, quality of life, and healing in living and dying. This focus will serve as a basis for our professional identity, strengthen our endeavors, and provide the ontological and epistemological basis for our continuing evolution as a practice profession.

Clinical ethics residency for nurses: an education model to decrease moral distress and strengthen nurse retention in acute care.

The experience of unaddressed moral distress can lead to nurse attrition and/or distancing from patients, compromising patient care. Nurses who are confident in their ethical decision making abilities and moral agency have the antidote to moral distress for themselves and their colleagues and can act as local or institutional ethics resources. We describe a grant-funded model education program designed to increase ethics competence throughout the institution.

Profession at the crossroads: A dialog concerning the preparation of nursing scholars and leaders

The purpose of a practice disciplines terminal degree is to develop wise scholars to guide the profession in anticipating and meeting the health-related needs of those served via philosophical, conceptual/theoretical, and empirical inquiry on behalf of professional practice. Each of these dimensions is important for the disciplines ability to meet its obligations to society. However, contemporary circumstances have created a context within which the maturation of the profession may be threatened by an imbalance among the three dimensions of PhD education. Specifically, we discuss the possibility of a tilt toward the empirical at the expense of the other two. Yet, the philosophical and conceptual/theoretical dimensions are those that have permitted core disciplinary knowledge to be developed. We aim to create a dialog about current challenges and the responsibilities of the disciplines scholars for stewardship of the discipline and offer some strategies to ensure balance among the three equally important dimensions.

The ethical nursing care of transgender patients: an exploration of bias in health care and how it affects this population.

Among the patients on the Pickwick unit, a general surgical floor in a large metropolitan hospital, is Britney-May Harrison, a 24-yearold, single, white, male-to-female transgender patient who had an appendectomy yesterday. (This case is a composite based on our clinical experience.) She hasn’t yet had gender-reassignment surgery but says she is considering having it done in the next couple of years. Ms. Harrison has type 2 diabetes, a possible consequence of starting estrogen therapy several months ago. She buys the estrogen on the streets, she says, “because it’s just too hard to find a good doctor who will work with me on my hormones.” Now, along with the usual postoperative interventions, the care team has been trying to help Ms. Harrison control her blood glucose level. She doesn’t pay attention to her diet, she says, and frequently misses doses of her oral hypoglycemic drug. Samantha Connell, a relatively new nurse on the Pickwick unit, receives a change-of-shift report from Jennifer Young, who warns Ms. Connell that Ms. Harrison is “rude” and doesn’t listen. “He’s kind of a strange one,” Ms. Young says. “His crossdressing is purely attention-seeking behavior.” Ms. Connell notices that the physicians making their morning rounds have gathered outside of the patient’s room. The senior resident, Dr. Marshall, says, quite loudly, “This is a 24-year-old male, two days postappendectomy, with uncontrolled type 2 diabetes. His surgical site is clean; it’s been healing well.” He adds, “Oh, and she prefers the name Britney-May.” The other physicians and residents giggle quietly. Ms. Connell is shocked and puzzled. In nursing school she’d learned that nurses and other professionals should behave respectfully toward all patients; otherwise, accurate assessment and treatment are made much more difficult. She decides to do some Internet searching to find out more about caring for transgender patients. She finds out that the word transgender is an umbrella term applied to people who live and identify, either full or part time, as the gender opposite from that assigned to them at birth. She further reads about the distinction between the terms sex and gender and between sexual orientation and gender identity. • Sex refers to biologic sex—male or female or intersex—according to genetics and internal and external reproductive organs. • Gender refers to a person’s identity and social classification based on masculine or feminine qualities and personality traits. • Sexual orientation refers to one’s sexual attraction to others—men, women, both, neither, or The Ethical Nursing Care of Transgender Patients

Ethics and Human Rights Issues Experienced by Psychiatric-Mental Health and Substance Abuse Registered Nurses

BACKGROUND: The ethics and human rights issues experienced by psychiatric-mental health and substance-abuse registered nurses (P-MH and SA RNs) and how disturbed they are by the issues are not known. OBJECTIVE: The purpose of this study was to identify the frequency of ethics and human rights issues experienced by P-MH and SA RNs and how disturbing the issues are to them. STUDY DESIGN: Using Dillman’s (1978) Total Design Method, a survey of more than 8,000 RNs in six New England states was conducted. From the final sample size of 2,090 New England RN participants, responses from 162 participants who identified themselves as P-MH(n = 145) or SA (n = 17) RNs were further analyzed using descriptive statistics. RESULTS: Protecting patients’ rights and human dignity and providing nursing care with possible health risks to the RN were identified as the most frequently experienced ethics and human rights issues. Staffing patterns that limit patient access to nursing care and implementing managed care policies that threaten the quality of patient care were identified as the most disturbing issues. Forty-one percent of the RNs reported experiencing ethics and human rights issues daily or one to four times per week in their clinical practices. CONCLUSIONS: P-MH and SA RNs in New England encounter ethics and human rights issues in practice more frequently than all other RNs practicing in New England.

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.

Conceptualizing surrogate decision making at end of life in the intensive care unit using cognitive task analysis

BACKGROUND Surrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. PURPOSE To identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU. METHODS Qualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical centers ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews. DISCUSSION The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDMs judgment about the acceptability of either the patients medical treatments or his or her condition. CONCLUSION The framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs.

Exercising Nursing Essential and Effective Freedom in Behalf of Social Justice: A Humanizing Model.

This article expands upon previous work by the authors to develop a model of nursing essential and effective freedom to facilitate nursing action in behalf of social justice. The article proposes that while social justice is rooted in nursings ontological, epistemological, and moral foundations, the disciplines social justice mandate is constrained by its historical and contemporary location within an institutionalized medical paradigm. We present a model of nursing “essential” and “effective” freedom based on the philosophy of Bernard Lonergan to illustrate how nursing can transcend these barriers. This humanizing model is illustrated through personal narratives of the authors.

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.

Ethical Analysis of a Qualitative Researcher's Unease in Encountering a Participant's Existential Ambivalence.

Gaining in-depth understanding of the experiences of persons who have suffered traumatic events with physical and psychological sequelae is important for building effective interventions. However, qualitative research of this kind can be emotionally difficult for the researcher whose research interests derive from practice experiences with the population studied. It may be difficult for the researcher to separate the role of inquirer from that of practitioner. We explore this issue using ethical analysis to differentiate the responsibilities of the researcher from those of the clinician. In the first part of the chapter, we provide some background on the population studied and traumatic spinal cord injury and its aftermath as context for the issues raised by the narrative. Then, we describe briefly the first authors research exploring the meaning of bodily changes and embodiment in persons who have suffered a traumatic spinal cord injury. We provide the part of Jacks story that most troubled the researcher and led her to discuss the situation with an ethics colleague. Finally, we use the tools of moral reasoning, ethical analysis, and principles of research ethics to explore the pertinent excerpt of the narrative. The resulting clarifications are laid out for the reader with the intent of assisting other qualitative researchers in determining the extent and limits of their obligations to participants of qualitative studies, especially those that explore sensitive issues.