Patricia Rodney

Reinterpretations Across Studies: An Approach to Meta-Analysis

The authors undertook a qualitative meta-analysis of their own studies to examine the context of health care and health care relationships. They “translated” selected concepts and metaphors from each study through those of the other studies, yielding new interpretations. In this article, they present their methods, discuss possible applications of this approach, and examine some issues that remain unresolved in the area of qualitative meta-analysis. They offer this approach, which produced broader perspectives than the individual studies afforded, as a promising way of synthesizing qualitative findings, providing a foundation for praxis, and influencing practice toward health and social justice.

Access to Primary Care From the Perspective of Aboriginal Patients at an Urban Emergency Department

In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers’ assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.

Health Care Relationships in Context: An Analysis of Three Ethnographies

A qualitative meta-analysis of three ethnographic studies conducted by the original investigators of those studies yielded new understandings of the dynamics of health care relationships in context. Through this analysis, the authors show that moral judgments and decision making in health care are highly relational and contextual. The use of power to compel health care providers and patients to comply with organizational practices is shown as fundamental to organizational functioning, and nurses participate in activities that often perpetuate conditions that contribute to their own moral distress. Furthermore, resistant actions often operate to sustain the practice patterns and ideologies being resisted. The authors call for an understanding of moral distress as relational and for collective strategies to counter practices that thwart ethical practice.

Inequities in health and healthcare viewed through the ethical lens of critical social justice: contextual knowledge for the global priorities ahead.

The authors use the backdrop of the Healthy People 2010 initiative to contribute to a discussion encompassing social justice from local to national to global contexts. Drawing on findings from their programs of research, they explore the concept of critical social justice as a powerful ethical lens through which to view inequities in health and in healthcare access. They examine the kind of knowledge needed to move toward the ideal of social justice and point to strategies for engaging in dialogue about knowledge and actions to promote more equitable health and healthcare from local to global levels.

Toward interventions to address moral distress Navigating structure and agency

Background: The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience. Discussion: Some researchers suggest that a closer examination of how socio-political structures influence healthcare delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress. Conclusion: We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced by—and influence—the complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions.

Moral distress in intensive care unit professionals is associated with profession, age, and years of experience

PURPOSE To determine which demographic characteristics are associated with moral distress in intensive care unit (ICU) professionals. METHODS We distributed a self-administered, validated survey to measure moral distress to all clinical personnel in 13 ICUs in British Columbia, Canada. Each respondent to the survey also reported their age, sex, and years of experience in the ICU where they were working. We used multivariate, hierarchical regression to analyze relationships between demographic characteristics and moral distress scores, and to analyze the relationship between moral distress and tendency to leave the workplace. RESULTS Response rates to the surveys were the following: nurses--428/870 (49%); other health professionals (not nurses or physicians)--211/452 (47%); physicians--30/68 (44%). Nurses and other health professionals had higher moral distress scores than physicians. Highest ranked items associated with moral distress were related to cost constraints and end-of-life controversies. Multivariate analyses showed that age is inversely associated with moral distress, but only in other health professionals (rate ratio [95% confidence interval]: -7.3 [-13.4, -1.2]); years of experience is directly associated with moral distress, but only in nurses (rate ratio (95% confidence interval):10.8 [2.6, 18.9]). The moral distress score is directly related to the tendency to leave the ICU job, in both the past and present, but only for nurses and other non-physician health professionals. CONCLUSION Moral distress is higher in ICU nurses and other non-physician professionals than in physicians, is lower with older age for other non-physician professionals but greater with more years of experience in nurses, and is associated with tendency to leave the job.

Preserving the Self: The Process of Decision Making About Hereditary Breast Cancer and Ovarian Cancer Risk Reduction:

Women who carry BRCA1 or BRCA2 (BRCA1/2) gene mutations have up to an 88% lifetime risk of breast cancer and up to a 65% lifetime risk of ovarian cancer. Strategies to address these risks include cancer screening and risk-reducing surgery (i.e., mastectomy and salpingo-oophorectomy). We conducted a grounded theory study with 22 BRCA1/2 mutation-carrier women to understand how women make decisions about these risk-reducing strategies. Preserving the self was the overarching decision-making process evident in the participants’ descriptions. This process was shaped by contextual conditions including the characteristics of health services, the nature of hereditary breast and ovarian cancer risk-reduction decisions, gendered roles, and the women’s perceived proximity to cancer. The women engaged in five decision-making styles, and these were characterized by the use of specific decision-making approaches. These findings provide theoretical insights that could inform the provision of decisional support to BRCA1/2 carriers.

Parents as Caregivers for Children with Schizophrenia: Moral Dilemmas and Moral Agency

Because the ability of people with schizophrenia to achieve anticipated success and independence is compromised, many of their parents assume responsibility for protecting, nurturing, and directing care for their offspring. The emotional, social, and financial challenges of caregiving, extended beyond the usual child-rearing duration, are complicated by the societal designation of their children as adults. Decisions about caregiving involve many practical and moral dilemmas. In this article, we examine several dilemmas encountered by parents who try to fulfill their perceived responsibility to care for adult children with schizophrenia. After exploring the related concept of moral agency, we close with some reflections on the assumptions surrounding psychiatric care and parental responsibility.

Causes of moral distress in the intensive care unit: A qualitative study

PURPOSE The purpose of the study is to examine the causes of moral distress in diverse members of the intensive care unit (ICU) team in both community and tertiary ICUs. MATERIALS AND METHODS We used focus groups and coding of transcripts into themes and subthemes in 2 tertiary care ICUs and 1 community ICU. RESULTS Based on input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported causes of moral distress were concerns about the care provided by other health care workers, the amount of care provided (especially too much care at end of life), poor communication, inconsistent care plans, and issues around end of life decision making. CONCLUSIONS Causes of moral distress vary among ICU professional groups, but all are amenable to improvement.

Almutairi's Critical Cultural Competence model for a multicultural healthcare environment.

The increasing demographic changes of populations in many countries require an approach for managing the complexity of sociocultural differences. Such an approach could help healthcare organizations to address healthcare disparities and inequities, and promote cultural safety for healthcare providers and patients alike. Almutairis critical cultural competence (CCC) is a comprehensive approach that holds great promise for managing difficulties arising from sociocultural and linguistic issues during cross-cultural interactions. CCC has addressed the limitations of many other cultural competence approaches that have been discussed in the literature. Therefore, the purpose of this study is to define the construct of CCC and the theoretical components of the CCC.