Sarah Winch

Nurses' Moral Sensitivity and Hospital Ethical Climate: a Literature Review

Increased technological and pharmacological interventions in patient care when patient outcomes are uncertain have been linked to the escalation in moral and ethical dilemmas experienced by health care providers in acute care settings. Health care research has shown that facilities that are able to attract and retain nursing staff in a competitive environment and provide high quality care have the capacity for nurses to process and resolve moral and ethical dilemmas. This article reports on the findings of a systematic review of the empirical literature (1980 — February 2007) on the effects of unresolved moral distress and poor ethical climate on nurse turnover. Articles were sought to answer the review question: Does unresolved moral distress and a poor organizational ethical climate increase nurse turnover? Nine articles met the criteria of the review process. Although the prevailing sentiment was that poor ethical climate and moral distress caused staff turnover, definitive answers to the review question remain elusive because there are limited data that confidently support this statement.

Moral stress, moral climate and moral sensitivity among psychiatric professionals

The aim of the present study was to investigate the association between work-related moral stress, moral climate and moral sensitivity in mental health nursing. By means of the three scales Hospital Ethical Climate Survey, Moral Sensitivity Questionnaire and Work-Related Moral Stress, 49 participants’ experiences were assessed. The results of linear regression analysis indicated that moral stress was determined to a degree by the work place’s moral climate as well as by two aspects of the mental health staff’s moral sensitivity. The nurses’ experience of ‘moral burden’ or ‘moral support’ increased or decreased their experience of moral stress. Their work-related moral stress was determined by the job-associated moral climate and two aspects of moral sensitivity. Our findings showed an association between three concepts: moral sensitivity, moral climate and moral stress. Despite being a small study, the findings seem relevant for future research leading to theory development and conceptual clarity. We suggest that more attention be given to methodological issues and developing designs that allow for comparative research in other disciplines, as well as in-depth knowledge of moral agency.

Reluctance to care: a systematic review and development of a conceptual framework.

Primary lay carers are increasingly important in the care of patients with cancer, but their role can be complex and extended. Potential carers may feel anything from highly committed to not at all interested in caregiving, but powerful social norms pressure them to accept the role, and reluctance may be hidden to avoid censure. The purpose of this review was to gain insights into caregiving reluctance and its consequences. The findings were organized into 4 major dimensions: demographic, physical, psychological, and social. Three major outcomes were identified: deterioration in the carer-patient relationship, reduced quality of care, and institutionalization. Definitive answers to the review questions remain elusive. Choice seems to be a major indicator of caregiving reluctance, although reluctance may not remain static over the caregiving trajectory. Caregiving reluctance remains an underexplored topic, particularly in the context of cancer.

Reasons doctors provide futile treatment at the end of life: a qualitative study

Objective Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patients life. Design Semistructured in-depth interviews. Setting Three large tertiary public hospitals in Brisbane, Australia. Participants 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. Results Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the main reasons for futile care. Conclusions Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.

Ethics, Government and Sexual Health: insights from Foucault:

The work of Michel Foucault, the French philosopher who was interested in power relationships, has resonated with many nurses who seek a radically analytical view of nursing practice. The purpose of this article is to explore ‘ethics’ through a Foucauldian lens, in a conceptual and methodological sense. The intention is to provide a useful framework that will help researchers critically to explore aspects of nursing practice that relate to the construction of the self, morality and identity, be that nurse or patient related. The fundamentals of the research method of genealogy and the methods of ethics are reviewed. Using an example taken from the sexual health practice area, advice is given on how to structure data collection, incorporate interview data, avoid discourse determinism and measure resistance.

Constructing a Morality of Caring: Codes and values in Australian Carer Discourse

In this analysis I apply a Foucauldian approach to ethics to examine the politically prescribed moral and ethical character required of carers of aged persons at home in Australia and the role of nurses in shaping these behaviours. The work that spousal carers provide, although often founded on love and/or obligation, has been formalized through a variety of policy initiatives and technologies that serve to construct the moral approach they must adopt. This shaping of conduct at the most personal level takes place through the application of codes of behaviour policed largely by nurses. These codes redefine the mode of coexistence between an aged husband and wife and propose a new form of relationship that is derived from and supports policies of the deinstitutionalization of care services for elderly persons. In this way modern carer policy has drawn on knowledge and governance of the self to produce a morality of caring that is both authoritative and scientific.

Emergency medicine and futile care: Taking the road less travelled

Debate around medical futility has produced a vast literature that continues to grow. Largely absent from the broader literature is the role of emergency medicine in either starting measures that prove to be futile, withholding treatment or starting the end of life communication process with patients and families. In this discussion we review the status of the futility debate in general, identify some of the perceived barriers in managing futile care in the ED including the ethical and legal issues, and establish the contribution of emergency medicine in this important debate. We conclude that emergency physicians have the clinical ability and the legal and moral standing to resist providing futile treatment. In these situations they can take a different path that focuses on comfort care thereby initiating the process of the much sought after ‘good death’.

Managing the clinical setting for best nursing practice: a brief overview of contemporary initiatives

BACKGROUND Leadership strategies are important in facilitating the nursing profession to reach their optimum standards in the practice environment. AIM To compare and contrast the central tenets of contemporary quality initiatives that are commensurate with enabling the environment so that best practice can occur. KEY ISSUES Democratic leadership, accessible and relevant education and professional development, the incorporation of evidence into practice and the ability of facilities to be responsive to change are core considerations for the successful maintenance of practice standards that are consistent with best nursing practice. CONCLUSION While different concerns of management drive the adoption of contemporary approaches, there are many similarities in the how these approaches are translated into action in the clinical setting. IMPLICATIONS FOR NURSING MANAGEMENT Managers should focus on core principles of professional nursing that add value to practice rather than business processes.

What does “futility” mean? An empirical study of doctors’ perceptions

Objective: To investigate how doctors define and use the terms “futility” and “futile treatment” in end‐of‐life care.

Leadership: the critical success factor in the rise or fall of useful research activity

AIM To describe how momentum towards building research capacity has developed through aligning research activity with executive responsibility via strategic planning processes that direct operational structures and processes for research activity. BACKGROUND Reflecting on the development of research capacity over many years at complex tertiary referral hospitals reveals that building nursing knowledge is too important to be left to chance or whim but needs a strategic focus, appropriate resourcing and long-term sustainability through infrastructure. KEY ISSUES A number of key approaches we uncovered as successful include: (i) articulation of questions consistent with the strategic direction of the health context that can be addressed through research evidence; (ii) engagement and dissemination through making research meaningful; and (iii) feedback that informs the executive about the contribution of research activity to guide policy and practice decisions. CONCLUSIONS Leadership teams need to ensure that the development of research knowledge is a strategic priority. The focus also needs to be more broadly on creating research capacity than focussing on small operational issues. IMPLICATIONS FOR NURSING MANAGEMENT Research capacity is developed when it is initiated, supported and monitored by leadership.