Unable to answer the call of our patients: mental health nurses’ experience of moral distress When health practitioners’ moral choices and actions are thwarted by constraints, they may respond with feelings of moral distress. In a Canadian hermeneutic phenomenological study, physicians, nurses, psychologists and non‐professional aides were asked to identify care situations that they found morally distressing, and to elaborate on how moral concerns regarding the care of patients were raised and resolved. In this paper, we describe the experience of (...) moral distress related by nurses working in mental healthcare settings who believed that lack of resources (such as time and staff) leads to dispiritedness, lack of respect, and absence of recognition (for both patients and staff) which severely diminished their ability to provide quality care. The metaphors of flashlight and hammer are used to elaborate nurses’ possible responses to intolerable situations. (shrink)

Once a term used primarily by moral philosophers, “moral distress” is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? “Plight” encompasses not (...) only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of “efficiency,” is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals’ moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim. (shrink)

The moral distress of psychologists working in psychiatric and mental health care settings was explored in an interdisciplinary, hermeneutic phenomenological study situated at the University of Alberta, Canada. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychologists described specific incidents in which they felt their integrity had been compromised by such factors as institutional and interinstitutional demands, team conflicts, and interdisciplinary disputes. They described dealing with the resulting moral distress by such means as (...) silence, taking a stance, acting secretively, sustaining themselves through work with clients, seeking support from colleagues, and exiting. Recognizing moral distress can lead to a significant shift in the way we perceive moral choices and understand the moral context of practice. (shrink)

The term compassion fatigue has come to be applied to a disengagement or lack of empathy on the part of care-giving professionals. Empathy and emotional investment have been seen as potentially costing the caregiver and putting them at risk. Compassion fatigue has been equated with burnout, secondary traumatic stress disorder, vicarious traumatization, secondary victimization or co-victimization, compassion stress, emotional contagion, and counter-transference. The results of a Canadian qualitative research project on nurses? experience of compassion fatigue are presented. Nurses, self-identified as (...) having compassion fatigue, described a change in their practice by which they began to shield and distance themselves from the suffering of patients and families. Time to help patients and families cope with suffering seemed unavailable, and many felt they were running on empty and, ultimately, impotent as nurses. Feelings of irritability, anger, and negativity arose, though participants described denying or ignoring these emotions as a way to try to survive their work day. Difficulties with work carried over into the nurses? personal lives, affecting their relationships with family and friends. Such experiences invariably called into question the participants? identity, causing them to reflect on the kind of nurse they were. The participants? compassion fatigue created a sense of hopelessness regarding positive change, although some nurses described strategies that seemed to help alleviate their compassion fatigue. (shrink)

Corporate and commercial values are inducing some healthcare organizations to prescribe a customer service model that reframes the provision of nursing care. In this paper it is argued that such a model is incommensurable with nursing conceived as a moral practice and ultimately places nurses at risk. Based upon understanding from ongoing research on compassion fatigue, it is proposed that compassion fatigue as currently experienced by nurses may not arise predominantly from too great a demand for compassion, but rather from (...) barriers to enacting compassionate care. These barriers are often systemic. The paradigm shift in which healthcare environments are viewed as marketplaces rather than moral communities has the potential to radically affect the evolution of nursing as a discipline. (shrink)

There are many ethical issues arising for practitioners in what are termed the boundaries of professional helping relationships. In this article, the authors argue that the boundary metaphor is not sufficient for conceptualizing these ethical issues and propose that alternative metaphors be considered. The use of a different metaphor might allow practitioners to re-vision the relationship issues in a more realistic, richer, and holistic way. Those explored here include highway, bridge, and territory. For the authors, it is territory that seems (...) to hold the greatest promise. (shrink)

The movie, The terminal, is used to illustrate Mac Intyre's description of virtue ethics. The terminal is a mythical tale about a traveler, Viktor Navorski, who is stranded by circumstances in a New York airport. Viktor is a person who, without a strict reliance on duty or rules, has developed the disposition to act well despite variation in his circumstances. His character is revealed in contrast to that of three other characters: a cleaner, a flight attendant and the airport manager. (...) Stories like this one may be a good way to open dialogue among clinicians about being virtuous as a practitioner. Such dialogue may make striving to be virtuous an acceptable goal for practitioners and less like an idealistic, pseudo-goal for those aiming for sainthood. (shrink)

Human rights may be the most globalized political value of our times. The rights paradigm has been criticized, however, for being theoretically unsound, legalistic, individualistic and based on the assumption that there is a given and universal humanness. Its use in the area of health is relatively new. Proponents point to its power to frame health as an entitlement rather than a commodity. The problems and the possibilities of a rights approach in addressing health ethics issues are explored in this (...) article. (shrink)

Experiences of moral distress encountered in psychiatric practice were explored in a hermeneutic phenomenological study. Moral distress is the state experienced when moral choices and actions are thwarted by constraints. Psychiatrists describe struggling ‘to do the right thing’ for individual patients within a societal system that places unrealistic demands on psychiatric expertise. Certainty on the part of the psychiatrist is an expectation when judgments of dangerousness and/or the need for coercive treatments are made. This assumption, however, ignores the uncertainty and (...) complexity of reality. Society entrusts psychiatrists to care for and treat those among its most vulnerable members: persons deemed to have a severely diminished capacity for autonomy due to a mental disorder. Simultaneously, psychiatrists are held accountable by society for the protection of the public. Moral distress arose for psychiatrists in their efforts to fulfill both roles. They described an ‘outsider/insider’ status and the ways in which they attempted to cope with moral distress. (shrink)

People with mental illness are subjected to stigma and discrimination and constantly face restrictions in the exercise of their political, civil and social rights. Considering this scenario, mental health, ethics and human rights are key approaches to advance the well-being of persons with mental illnesses. The study was conducted to review the scope of the empirical literature available to answer the research question: What evidence is available regarding human rights and ethical issues regarding nursing care to persons with mental illnesses? (...) A scoping review methodology guided by Arksey and O’Malley was used. Studies were identified by conducting electronic searches on CINAHL, PubMed, SCOPUS and Hein databases. Of 312 citations, 26 articles matched the inclusion criteria. The central theme which emerged from the literature was “Ethics and Human Rights Boundaries to Mental Health Nursing practice”. Mental health nurses play a key and valuable role in ensuring that their interventions are based on ethical and human rights principles. Mental health nurses seem to have difficulty engaging with the ethical issues in mental health, and generally are dealing with acts of paternalism and with the common justification for those acts. It is important to open a debate regarding possible solutions for this ethical dilemma, with the purpose to enable nurses to function in a way that is morally acceptable to the profession, patients and members of the public. This review may serve as an instrument for healthcare professionals, especially nurses, to reflect about how to fulfil their ethical responsibilities towards persons with mental illnesses, protecting them from discrimination and safeguarding their human rights, respecting their autonomy, and as a value, keeping the individual at the centre of ethical discourse. (shrink)

This article reports the findings of a qualitative study that explored the organizational influences on moral distress for health professionals working in pediatric intensive care units across Canada. Participants were recruited to the study from PICUs across Canada. The PICU is a high-tech, fast-paced, high-pressure environment where caregivers frequently face conflict and ethical tension in the care of critically ill children. A number of themes including relationships with management, organizational structure and processes, workload and resources, and team dynamics were identified. (...) This study provides a rare and important multi-disciplinary perspective on this topic and the findings have implications for administrators and leaders who seek to improve the moral climate of healthcare delivery. (shrink)

When nurses have active and untreated addictions, patient safety may be compromised and nurse-health endangered. Genuine responses are required to fulfil nurses' moral obligations to their patients as well as to their nurse-colleagues. Guided by core elements of relational ethics, the influences of nursing organizational responses along with the practice environment in shaping the situation are contemplated. This approach identifies the importance of consistency with nursing values, acknowledges nurses interdependence, and addresses the role of nursing organization as moral agent. By (...) examining the relational space, the tension between what appears to be opposing moral responsibilities may be healed. Ongoing discourse to identify authentic actions for the professional practice issue of nursing under the influence is called upon. (shrink)

Background: Limited knowledge of the experiences of conflicts of conscience found in nursing literature. Objectives: To explore the individual experiences of a conflict of conscience for neonatal nurses in Alberta. Research design: Interpretive description was selected to help situate the findings in a meaningful clinical context. Participants and research context: Five interviews with neonatal nurses working in Neonatal Intensive Care Units throughout Alberta. Ethical consideration: Ethics approval from the Health Research Ethics Board at the University of Alberta. Findings: Three common (...) themes emerged from the interviews: the unforgettable conflict with pain and suffering, finding the nurse’s voice, and the unique proximity of nurses. Discussion and conclusion: The nurses described a conflict of conscience when the neonate in their care experienced undermanaged pain and unnecessary suffering. During these experiences, they felt guilty, sad, hopeless, and powerless when they were unable to follow their conscience. Informal ways to follow their conscience were employed before declaration of conscientious objection was considered. This study highlights the vital importance of respecting a conflict of conscience to maintain the moral integrity of neonatal nurses and exposes the complexities of conscientious objection. (shrink)

The majority of healthcare professionals regularly witness fragility, suffering, pain and death in their professional lives. Such experiences may increase the risk of burnout and compassion fatigue, especially if they are without self-awareness and a healthy work environment. Acquiring a deeper understanding of vulnerability inherent to their professional work will be of crucial importance to face these risks. From a relational ethics perspective, the role of the team is critical in the development of professional values which can help to cope (...) with the inherent vulnerability of healthcare professionals. The focus of this paper is the role of Communities of Practice as a source of resilience, since they can create a reflective space for recognising and sharing their experiences of vulnerability that arises as part of their work. This shared knowledge can be a source of strength while simultaneously increasing the confidence and resilience of the healthcare team. (shrink)

Traditionally, physicians and parents made decisions about children’s health care based on western practices. More recently, with legal and ethical development of informed consent and recognition for decision making, children are becoming active participants in their care. The extent to which this is happening is however blurred by lack of clarity about what children — of diverse levels of cognitive development — are capable of understanding. Moreover, when there are multiple surrogate decision makers, parental and professional conflict can arise concerning (...) children’s ‘best interest’. Giving children a voice and offering choice promotes their dignity and quality of life. Nevertheless, it also presents with many challenges. Case studies using pseudonyms and changed situational identities are used in this article to illuminate the complexity of ethical challenges facing nurses in end-of-life care with children and families. (shrink)

It is considered the right of children to have their pain managed effectively. Yet, despite extensive research findings, policy guidelines and practice standard recommendations for the optimal management of paediatric pain, clinical practices remain inadequate. Empirical evidence definitively shows that unrelieved pain in children has only harmful consequences, with no benefits. Contributing factors identified in this undermanaged pain include the significant role of nurses. Nursing attitudes and beliefs about children’s pain experiences, the relationships nurses share with children who are suffering, (...) and knowledge deficits in pain management practices are all shown to impact unresolved pain in children. In this article, a relational ethics perspective is used to explore the need for nurses to engage in authentic relationships with children who are experiencing pain, and to use evidence-based practices to manage that pain in order for this indefensible suffering of children to end. (shrink)

A summary of the existing literature related to moral distress (MD) and the paediatric intensive care unit (PICU) reveals a high-tech, high-pressure environment in which effective teamwork can be compromised by MD arising from different situations related to: consent for treatment, futile care, end-of-life decision making, formal decision-making structures, training and experience by discipline, individual values and attitudes, and power and authority issues. Attempts to resolve MD in PICUs have included the use of administrative tools such as shift worksheets, the (...) implementation of continuing education, and encouragement to report. The literature does not yet show these approaches to be effective in the resolution of MD. The need to acknowledge MD among PICU teams is discussed and an argument made that, to facilitate understanding among team members, practice stories need to be shared. (shrink)

Integrated developmental and elemental information in teeth provide a unique framework for documenting breastfeeding histories, physiological disruptions, and neurotoxicant exposure in humans and our primate relatives, including ancient hominins. Here we detail our method for detecting the consumption of mothers’ milk and exploring health history through the use of laser ablation‐inductively coupled plasma‐mass spectrometry (LA‐ICP‐MS) mapping of sectioned nonhuman primate teeth. Calcium‐normalized barium and lead concentrations in tooth enamel and dentine may reflect milk and formula consumption with minimal modification during (...) subsequent tooth mineralization, particularly in dentine. However, skeletal resorption during severe illness, and bioavailable metals in nonmilk foods, can complicate interpretations of nursing behavior. We show that explorations of the patterning of multiple elements may aid in the distinction of these important etiologies. Targeted studies of skeletal chemistry, gastrointestinal maturation, and the dietary bioavailability of metals are needed to optimize these unique records of human health and behavior. (shrink)

Building from J.L. Austin's concept of ‘performative,’ this essay explores the production of subjectivity and of educational subjects by applying important work from Judith Butler on Foucault, Derrida, and as centrally illustrative, through an analysis of sex and gender. Given this analytical framework, the turn is then to queer performativity and the possibility of performative power in pedagogy. The last draws assistance from Valerie Walkerdine, Homi Bhabha and especially James Donald.

Concerns over conflicts of interest in academic research and medical practice continue to provoke a great deal of discussion. What is most obvious in this discourse is that when COIs are declared, or perceived to exist in others, there is a focus on both the descriptive question of whether there is a COI and, subsequently, the normative question of whether it is good, bad or neutral. We contend, however, that in addition to the descriptive and normative, COI declarations and accusations (...) can be understood as performatives. In this article, we apply J.L. Austin’s performative speech-act theory to COI discourses and illustrate how this works using a contemporary case study of COI in biomedical publishing. We argue that using Austin’s theory of performative speech-acts serves to highlight the social arrangements and role of authorities in COI discourse and so provides a rich framework to examine declarations, accusations and judgements of COI that often arise in the context of biomedical research and practice. (shrink)

The literature on brain activity in depression and anxiety is reviewed with an on highlighting discrepancies and inconsistencies. In particular, and posterior asymmetries have been reported for both depression anxiety, but the magnitude and direction of these asymmetries has been We propose that by identifying subtypes of depression and anxiety of these inconsistencies can be explained. In addition, we review suggesting that issues of comorbidity are important to consider in to account for regional brain activity in depression and anxiety.

Current conceptions of human language include a gestural component in the communicative event. However, determining how the linguistic and gestural signals are distinguished, how each is structured, and how they interact still poses a challenge for the construction of a comprehensive model of language. This study attempts to advance our understanding of these issues with evidence from sign language. The study adopts McNeill's criteria for distinguishing gestures from the linguistically organized signal, and provides a brief description of the linguistic organization (...) of sign languages. Focusing on the subcategory of iconic gestures, the paper shows that signers create iconic gestures with the mouth, an articulator that acts symbiotically with the hands to complement the linguistic description of objects and events. A new distinction between the mimetic replica and the iconic symbol accounts for the nature and distribution of iconic mouth gestures and distinguishes them from mimetic uses of the mouth. Symbiotic symbolization by hand and mouth is a salient feature of human language, regardless of whether the primary linguistic modality is oral or manual. Speakers gesture with their hands, and signers gesture with their mouths. (shrink)

Our aim is to explore and develop notions of objectivity that are useful and appropriate for critical realist empirical research. In Part I, we provided an initial definition that introduced the idea that objectivity is a value that must be chosen but that its significance is rooted in a series of other epistemological and ontological matters. We also addressed why it is worthwhile in realist terms to develop the notion of objectivity, and began to develop a revision of the concept (...) to recognise the role of subjectivities. This, we maintain, is an important clarification in developing social research. Part II explores the linkages between objectivity and situated action. In Part II we argue that the growth of knowledge requires engagement and critical analysis. We develop the idea that if subjects are engaged through multiple standpoints, then objectivity becomes significant as a lever of agency in the service of dialogue and debate and of transformations. Again, our aim is to be of use to practical researchers by providing underlying arguments. Specifically, we argue that objectivity is a bridge between the subjectivities of subjects and the rest of the real world. In so doing, the paper works through various desirable characteristics of an adequate theorisation of knowledge that could make objectivity part of the ontological underpinnings as well as the daily practices of a realist researcher. Objectivity thus links philosophical work to the everyday work of realist researchers. (shrink)

As neuroscience methods begin to dominate emotion research it is critical for researchers to remember that peripheral embodiments are critical to understanding emotional experience and emotion—behavior links. Much of modern emotion research assumes reliable mind—body connections that suggest that changes in emotional states influence bodily responses and, vice versa, that somatovisceral information shapes emotional experiences. However, there may be important qualifications to the link between the mind and the (peripheral) body. For example, the ability to sense internal and external bodily (...) states declines in older age as does activation of physiological systems, all of which may contribute to an impairment in emotional experiences and how emotions influence behavior. I describe this phenomenon as maturational dualism and suggest implications of this for emotion in older adults. (shrink)

Rationale, aims and objectives: Bioethics and professionalism are standard subjects in medical training programmes, and these curricula reflect particular representations of meaning and practice. It is important that these curricula cohere with the actual concerns of practicing clinicians so that students are prepared for real-world practice. We aimed to identify ethical and professional concerns that do not appear to be adequately addressed in standard curricula by comparing ethics curricula with themes that emerged from a qualitative study of medical practitioners. Method: (...) Curriculum analysis: Thirty-two prominent ethics and professionalism curricula were identified through a database search and were analysed thematically. Qualitative study: In-depth, semi-structured interviews were conducted with 20 medical practitioners. Participants were invited to reflect upon their perceptions of the ways in which values matter in their practices and their educational experiences. The themes emerging from the two studies were compared and contrasted. Results: While representations of meaning and value in ethics and professionalism curricula overlap with the preoccupations of practicing clinicians, there are significant aspects of ‘real-world’ clinical practice that are largely ignored. These fell into two broad domains: ‘sociological’ concerns about enculturation, bureaucracy, intra-professional relationships, and public perceptions of medicine; and epistemic concerns about making good decisions, balancing different kinds of knowledge, and practising within the bounds of professional protocols. Conclusions: Our findings support the view that philosophy and sociology should be included in medical school and specialty training curricula. Curricula should be reframed to introduce students to habits of thought that recognize the need for critical reflection on the social processes in which they are embedded, and on the philosophical assumptions that underpin their practice. (shrink)

An ancient and enduring cross-cultural mythology explores what the texts generally perceive as a paradox: the birth of white offspring to black parents, or black offspring to white parents. This mythology in the Hebrew Bible is limited to animal husbandry, but in Indian literature from the third century B.C.E. and Greek and Hebrew literature from the third or fourth century C.E. it was transferred to stories about human beings. These stories originally express a fascination with the dark skin of “Ethiopians” (...) , and a fantasy of white children born to them. But when ideas about human race arise in Europe after the sixteenth century, the stories reverse their color schemes and shift their emphasis to investigations of the paradox of black children born to white parents. In our day, racism is clearly a strong factor in the media fascination with court cases about in vitro fertilization in which black children are born to white parents. This development suggests that the symbolism of black and white was not originally, nor need be now, racist, but that, once racism is current, it is hard to reclaim the nonjudgmental innocence of the earlier texts. Many of these texts explained the paradox of children who differ from their parents in color by invoking the concept of parental impression , which argues that whatever a woman thinks of or sees at the moment of conception influences the physical form of the child. This doctrine, which was known in ancient Israel, in Greece, in ancient India, and in Europe well into the twentieth century, primarily addresses an entirely different obsession—the problem of paternal insecurity—and generally draws heavily on sexist and misogynist attitudes toward women. Yet, when it was appropriated into the narratives of off-color offspring, it offered, in place of the more obvious explanation , an alternative fantasy that softened the culpability of women. So, too, when applied to stories of color-contrasting offspring in European narratives, even after the sixteenth century,the idea of parental impression functioned as a force against racism ; the Lamarckian or Lysenkan idea of the inheritance of acquired characteristics—the privileging of nurture over nature—argues against the belief that one’s racial stock determines who one is. Thus this doctrine, farfetched as it seems to us , dulled the edge of ancient antagonism toward women and modern European antagonism toward the descendants of the “Ethiopians.” A study of the variations of this myth across cultures has much to tell us about the ways in which myths about women and myths about people of dark skin color are transformed under the pressure of later tropes of sexism and racism. (shrink)

Although some scholars have argued that Aristotle makes deliberation seem independent of virtue, I argue that deliberation, properly understood, is ethical in the Rhetoric and the Nicomachean Ethics. Unlike modern scholars who separate the useful from the good and the prudent from the moral, Aristotle argues that speakers’ deliberative arguments seek what is good and beneficial, much as noble persons in the Ethics pursue the good and the beneficial in their actions. So regarded, the beneficial is not the enemy of (...) the excellent but its partner. I show that rhetorical argument is a flexible resource serving the different ends of deliberative, forensic and epideictic arguments. This article assesses the inventiveness, cogency and ethical implications of various rhetorical arguments, including argument from example and enthymeme. (shrink)