Inequitable access to health care, social inequities, and racist and discriminatory care has resulted in the trend toward poorer health outcomes for Indigenous infants and their families when compared to non‐Indigenous families in Canada. How Indigenous mothers experience care during an admission of their infant to the Neonatal Intensive Care Unit has implications for future health‐seeking behaviors which may influence infant health outcomes. Nurses are well positioned to promote positive health care interactions and improve (...) health outcomes by effectively meeting the needs of Indigenous families. This qualitative study was guided by interpretive description and the Two‐Eyed Seeing framework and aimed to understand how Indigenous mothers experience accessing and using the health care system for their infants. Data were collected by way of interviews and a discussion group with self‐identifying Indigenous mothers of infants less than two years of age living in Hamilton, Ontario, Canada. Data underwent thematic analysis, identifying nursing strategies to support positive health care interactions and promote the health and wellness of Indigenous infants and their families. Building relationships, providing holistic care, and taking a trauma‐informed approach to the involvement of child protection services are three key strategies that nurses can use to positively impact health care experiences for Indigenous families. (shrink)

Background: Moral distress has been experienced by about 67% of critical care nurses which causes many complications such as job dissatisfaction, loss of capacity for caring, and turnover for nurses and poor quality of care for patients as well as health system. Objective: The purpose of this research was to provide a moral empowerment program to nursing directors, school of nursing, and the heads of hospitals to reduce moral distress in nurses and improve the quality of care. (...) Methods: This research was a randomized clinical trial conducted in two groups and three stages before, after 2 weeks, and 1 month after the intervention in order to evaluate the changes in moral distress of 60 nurses working in adults’ intensive care unit wards of Al-Zahra teaching hospital of Isfahan University of Medical Sciences. Data were collected using the standard Hamric’s Moral Distress Scale (2012) and analyzed using SPSS software version 22. Ethical considerations: This study was approved by the Ethics Committee of Isfahan University of Medical Sciences, Isfahan, Iran. Results: Results showed that in the three stages, there was no significant difference between the mean score of moral distress before (4.12 ± 2.70), 2 weeks after (4.23 ± 2.70), and 1 month after the intervention (4.04 ± 2.54) in the control group (p > 0.05), while in the experimental group, there was a significant difference between the three stages (p 0.05). However, this score significantly decreased 1 month after the intervention (2.64 ± 2.23; p < 0.05). Conclusion: In this research, it was observed that moral empowerment program has been effective in reducing the mean score of moral distress. Therefore, it is recommended that nursing managers and hospital directors implement empowerment program, in order to reduce the moral distress of nurses and improve the quality of care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Lessons Learned in Room 208Katherine BakkeAuthor's Note. Parts of this story were previously shared here: https://theinterstitium.home.blog/2020/06/01/journeying-to-a-time-of-death/I remember the first time I saw a patient die. I was a medical student on my surgery rotation. Pushed to the sidelines of the resuscitation bay while the trauma team tended to a teenager injured in a motorcycle crash, my attention was drawn to the drama unfolding next door. There, a team (...) of physicians performed CPR on a man. While a curtain and a comforting social worker separated the patient's wife and daughter from the horrors of the resuscitation, I had a full view of everything. I watched as each chest compression threw the man's belly upward, like he had a bad bout of the hiccups. I watched as each pulse check yielded no return of blood flow. I watched as his wife and daughter clenched their hands in prayer, muttering, "Please, please, please." Then, the physician called the code. The instant the doctor pronounced him dead, I felt the presence of one less person in the room. I was surprised by how visceral this departure felt. It seemed like a sacred moment, a small proof that our bodies do indeed house our souls.I started paying close attention to how surgeons talked about death. Discussions of death seemed frequent in windowless work rooms amongst doctors, or in hushed conversations at the nurses station. Discussions of death were notably absent when talking with patients or their families. Sometimes, it seemed that the sicker the patient, the less likely their possible death was acknowledged. I [End Page E12] was fascinated by how challenging it was to speak honestly about our inevitable mortality. I began reading everything I could find about discussing end-of-life issues. I even conducted and published a systematic review on the subject. When it came time for me to begin my own surgical training, I carried with me a naive confidence, eager to engage in these conversations at the bedside.My time finally came eight months into my intern year. I was working in the intensive care unit and was "up" for the next admission. I got a call from the emergency department, saying a 68-year-old woman needed an ICU bed for a heart failure exacerbation. Her breathing was labored. They had given her IV Lasix, but I was told she might need BiPAP or other respiratory support while her heart failure was managed.Ten minutes later, she rolled into Room 208, and the ICU nurses started their work transferring her from the stretcher to the bed, applying EKG leads, a blood pressure cuff, and a pulse oximeter. I stood at the foot of the bed and quickly realized I had never taken care of a patient so ill. Her head drooped to her chest, every ounce of energy used to draw her next breath. She could only mumble indiscernible words; she hardly had the energy to open her eyes. I glanced at the monitor displaying her vitals: heart rate 120, SpO2 84%, BP 70/40. A foley catheter hung at the bedside, and no urine was present. "They gave her Lasix downstairs, right?" I asked the nurse. We both looked at the foley bag, and then at each other. I glanced at the patient's lips, which were dry and cracked. I pinched the skin at the top of the patient's hand, and it tented. I was pleased with my exam skills, and my ability to deduce that she was dehydrated. "This isn't heart failure," I thought, as I considered other reasons for her illness. The nurse awoke me from my self-congratulating stupor and reminded me sternly, "We need orders."The situation rapidly became more critical. The patient's arterial blood gas (ABG) showed a pattern of impending respiratory failure. Her daughters arrived at the bedside; one was wearing hospital scrubs. I introduced myself to them as the resident doctor caring for their mom. I asked if the daughter wearing scrubs had a healthcare background, foolishly thinking that doing so would build rapport. She curtly replied, "I... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Whisper Before You GoJohn K PettyDavid came with a bang.1A momentary prelude from a dysphonic chorus of pagers announce “Level 1 Pediatric Trauma—MVC ejected” before the abrupt crescendo of the trauma bay doors opening. He is maybe two. Maybe three–years–old. It is hard to tell when a child is strapped in, strapped down, nonverbal, intubated, and alone.The flight team speaks for him, “Four–year–old boy improperly restrained in (...) a single–vehicle crash into a ditch. He was partially ejected. He was unresponsive and pulseless at the scene. He got CPR and code drugs, and they got a pulse back. Emergency medical service (EMS) took him to the nearest hospital where they needled his chest, called for air transport, and scanned him up. He has been shocky for us since we picked him up. Glasgow Coma Scale (GCS) has been three the whole time. They said his head scan showed subarachnoid hemorrhage.”With the words of the flight team as background narrative, we get about doing our thing—hopefully more method and less madness. Bang, bang, bang! Check the tube. Vital signs. IV fluids. Place a chest tube. Hang the blood. Quick X–ray. Neuro exam—nothing. Get him off the board. Warm him up. Place the orogastric (OG) tube. Bang, bang, bang!The neurosurgery resident opens the CT scans from the other hospital. The brain and cervical spine scans show a disaster: some swelling and bleeding in the higher brain, but the worst damage is in the lower brain, brainstem, and top of the spinal cord. I have heard a neurosurgeon describe this pattern before as “internal decapitation.” Such language never makes it into the patient’s chart. For David the last two words of the neurosurgery consult note will eventually read, “Prognosis grim.”He remains unstable in the trauma bay. Inaction is death. We ultrasound his heart, abdomen, and pelvis. He has fluid that shouldn’t be around his heart. He is dying of the neuro injury we cannot control, but the pericardial fluid might be giving him shock, and we can control that. We can’t ignore the fluid. Shouldn’t ignore it. At least, wouldn’t ignore it. So, we bang up to the operating room. Squeezing blood. Spiking fluid. Oxygen tank and crash cart. Up we go.In the operating room, we do much and we do well. We release the fluid around the heart and find it was CPR, not heart injury that put it there. In the pericardial flash we get a view of the cardiac athlete, pounding like the 26th mile of the marathon. We explore the abdomen and find it swollen but innocent of an injury that would take his life. We place our lines and tubes as the neurosurgeons place theirs. If nothing else, we will be able to measure what lies ahead.“Good work, team,” and we bump the door on the way to the pediatric intensive care unit (PICU).The care in the PICU is more Apache brave than Gaelic knight—more bottles, fewer scissors. The curtains and carpets mute the tones. Our efforts continue, but I get a word that David’s father has arrived. He is sitting in a small, private waiting room off of the main PICU waiting room. The PICU staff colloquially refer to this as “the bad news room.” I take a seat next to a solitary man who is having the worst day of his life. His worst day so far.“I am Dr. Petty, and I am one of the doctors who is taking care of your son. I am very sorry about what has happened. Maybe you can tell me a little bit about what you understand is going on, and I’ll tell you what I know.” [End Page 17]He tells me that his wife was driving David back from her sister’s house, just the two of them. He doesn’t know what happened, but he got a call from the other hospital about the crash. His wife was badly hurt. He heard that David had died, but they got him back. Both were transferred up to the... (shrink)

We argue for the addition of trauma informed awareness, training, and skill in clinical ethics consultation by proposing a novel framework for Trauma Informed Ethics Consultation (TIEC). This approach expands on the American Society for Bioethics and Humanities (ASBH) framework for, and key insights from feminist approaches to, ethics consultation, and the literature on trauma informed care (TIC). TIEC keeps ethics consultation in line with the provision of TIC in other clinical settings. Most crucially, TIEC (like (...) TIC) is systematically sensitive to culture, history, difference, power, social exclusion, oppression, and marginalization. By engaging a neonatal intensive care ethics consult example, we define our TIEC approach and illustrate its application. Through TIEC we argue it is the role of ethics consultants to not only hold open moral spaces, but to furnish them in morally habitable ways for all stakeholders involved in the ethics consultation process, including patients, surrogates, and practitioners. (shrink)

Coronavirus disease 2019 (COVID‐19) has placed significant strain on United States’ health care and health care providers. While most Americans were sheltering in place, nurses headed to work. Many lacked adequate personal protective equipment (PPE), increasing the risk of becoming infected or infecting others. Some health care organizations were not transparent with their nurses; many nurses were gagged from speaking up about the conditions in their workplaces. This study used a descriptive phenomenological design to describe the lived (...) experience of acute care nurses working with limited access to PPE during the COVID‐19 pandemic. Unstructured interviews were conducted with 28 acute care nurses via telephone, WebEx, and Zoom. Data were analyzed using thematic analysis. The major theme, emotional roller coaster, describes the varied intense emotions the nurses experienced during the early weeks of the pandemic, encompassing eight subthemes: scared and afraid, sense of isolation, anger, betrayal, overwhelmed and exhausted, grief, helpless and at a loss, and denial. Other themes include: self‐care, ‘hoping for the best’, ‘nurses are not invincible’, and ‘I feel lucky’. The high levels of stress and mental assault resulting from the COVID‐19 crisis call for early stress assessment of nurses and provision of psychological intervention to mitigate lasting psychological trauma. (shrink)

After the death of Prophet Muhammad (p.b.u.h), one of the most significant debated topics of Muslims was the institution of caliphate. This institution caused crucial argumentations through the ages from Abu Bakr to Abd-al-Majid who was the hundreth khalifa. Some prominent issues in that regard as follows: How khalifa comes to power, who becomes khalifa, whether he is descended from Quraysh or not, which kind of traits khalifa should have, and how khalifa should behave in certain circumstances. While these arguments (...) were going on, caliphate was maintained based on the reign under some certain dynasties’ responsibilities after the Rashidun (rightly guided) Caliphs. Umayyads, Abbasids and Ottoman Dynasties were the most well-known ones of these dynasties. Throughout history, even though caliphate passed in one another’s hands among aforementioned dynasties, none of them did attempt to abolish this position. However, Turkish Muslims who became defeated with European occupation of non-western territories decided to abolish caliphate for the sake of modernization activities within the period of transition from imperialism to nation state. This decision brought about a trauma, which was much more critical than former argumentation around the position in Muslim world. Many congresses were organized in Islamic world in order to recover from this trauma. While this kind of quests were continuing, Muhammad Hamīdullah proposed “High Caliphate Council” in relation to rearrangement of caliphate in accordance with the conditions of Islamic countries. This proposal offers an applicable model to today’s modern nation states by establishing unity among them and leaving aside their conflicts and differences. This proposal offers a resolution of much-discussed matters of the position within the limits of principals. It also draws attention by showing a possibility of Islamic union in contemporary Islamic thought. Summary: The matters of who undertakes the management of societies, how rulers come to power and in what manners the rulers maintain the management have been discussed throughout history. It is seen that rulers adopted kingdom as regime before the period of the Prophet Muhammad (p.b.u.h). There was also two-person management. The discussions about this matter were also seen around khalifas who were the rulers of Muslims after the death of Prophet Muhammad (p.b.u.h). Some debated issues in that regards as follows: Who becomes khalifa, how he is elected, which traits he should possess, and so on. Caliphate continued its existence despite the discussions until the first quarter of the 14th Hijra era. Abolition of caliphate was a trauma for Muslims undoubtedly. From Anatolia to Egypt and from India to the Balkans, many attempts were carried out to recover from this trauma. However, this matter was oversimplified in the conditions of that period since it became a topic which was hushed over in just congresses and conventions. One of the people who wrote on this topic, which maintains its vitality even today was Muhammad Hamīdullah. He was an important Islamic scholar, a lawyer and a historian in Indian geography. Hamīdullah did deal caliphate by indicating its history broadly. The distinctive feature of Hamīdullah from others who wrote on this topic is that he also presented a considerable offer to solve the matter. In this sense, Hamīdullah experienced the trauma in his own life as all muslims did it with the abolition of caliphate. Hence he mentioned this matter in his writings in the mood of care and dignity of a scientist and also in feeling of a heartbroken muslim. Hamīdullah made clear that the method of election of the ruler differed throughout history. Indeed, the verses of Holy Qur’ān, the applications of the Prophet Muhammad (p.b.u.h) and the differences of Four Great Chaliphs on coming to power testified this claim. According to Hamīdullah, it is quite normal that the method of regime can vary according to the conditions of societies. He recommended acting based on timeless rules rather than the changes that vary according to conditions and places. He also stated that the regime which Islam approves is a combination of kingdom and democracy in his lines dealing with methods of regime. To him, kingdom is the method of regime of empire. Empire is the regime in which various nationalities live together with all their differences and interact with one another intensely and in which the rulers rule over wide borders. On the other hand, Islamic world lost its edges of empire, changed its regime and divided to nation states after the decline of the Ottoman Empire and Mughal Empire which were established by Muslims. On the contrary, westerners attempted to establish a head empire several times after building nation states in Europe. Some of them are UN, NATO, EU, to name but a few. In our opinion, in the transition process of Muslim rulers from empire to nation state, Hamīdullah made an offer to accomodate Islamic law in state law, Islamic politic and administrative principles in politics and administration practices, Islamic education system in education system, and principles of Islamic economics in economic decisions of government using the Prophet Muhammed’s life as a base. He also explained to Muslims that the method of regime can be changed and the essential matter is to apply Islamic management principles in such a new situation. He played a role in clearing the way for Muslims by indicating that the method of Islamic regime can be changed according to conditions but the principles of Islam are unalterable. To the writer of these lines, Hamīdullah intimates that it is not so true to stick to the form of the process in Muslim territories in which a compulsory transition from the empires or multinational social structures to the nation state structures have been experienced for the last two ages. However, the first matter to dwell on should be whether the ruler of the government behaves in accoradance with the principles of Islam or not. To Hamīdullah, the second matter is that even though Muslim countries had to enter in the process of becoming nation states, Muslims should make an effort to establish supra-state associations as required by Islam. In this respect, Hamīdullah’s proposal is “High Caliphate Council”. This council is a considerable offer presented to Muslim countries in the age when a universal caliphate is not possible and Muslims head towards a unified state form all over the world. Today, this offer recommends countries of which great majority is Muslims and in which Muslims are minority to meet on a common ground rather than conflict because of differences among them. The High Caliphate Council is an institute consists of presidents or hereditary administrators as leading and regular members and so it avoids regional competition. It is established by Muslim presidents who shares the chair alternately. Based on this, all Muslim presidents play a role altogether in this council without need to be Sunni, Shia, or from Quraysh. The High Caliphate Council is a reflection of a dream, which started a century and half a century ago but is required more today. It is also a reflection of the discourse of “Islamic Union” in Contemporary Islamic Thought. The Caliphate Council and International Islamic Legists’ Association, which is the first practical step of the council can be seen as the theory of a new world order based on the unity principle of Islam. Hamīdullah does not consider this order not only in the range of belief but also with the aim of institutionalizing ‘ijmā (consensus of Islamic legists) and qiyās(legal analogy). He stated that International Islamic Legists’ Association, which is a scientific institution could not be established beforetime by Muslims spread on three continents due to lacking of communication among them. However, thanks to today’s possibilities, the establishment of such association is easier today. Hamīdullah found dynamic solutions such these two institutions for the realization of caliphate, which is a religious necessity. He marked an era for Muslims in the period of time when they are on a quest. (shrink)

Having a premature or critically ill infant in a neonatal intensive care unit is a traumatic experience for parents that can alter their lives. Parents navigate complex emotions of fear, unc...

Background:Moral distress is a significant concern for nurses as it can lead to burnout and intentions to leave the profession. Pediatric nurses encounter stressful and ethically challenging situations when they care for suspected victims of child maltreatment. Data on pediatric nurses’ moral distress are limited, as most research in this field has been done in adult inpatient and intensive care units.Aim:The purpose of this study was to describe pediatric nurses’ moral distress and evaluate the impact of caring (...) for suspected victims of child maltreatment on nurses’ moral distress, burnout, and intention to leave. Design and method: This descriptive cross-sectional correlational study was conducted in a mid-Atlantic, urban area Magnet pediatric level I trauma center that cares for over 1800 cases of suspected child maltreatment annually. An anonymous electronic survey was sent to all the nurses working at the hospital.Ethical considerations:Institutional Review Board approval was received from the first author’s university and the hospital where the study was conducted.Findings:Overall, nurses ( N = 146) reported low levels of moral distress with a mean score of 59.54 (SD = 49.22) and a range of 0–300 on the Moral Distress Scale Neonatal–Pediatric version. Although the frequency of caring for suspected child maltreatment victims did not affect nurses’ moral distress, caring for victims with fatal maltreatment contributed to nurses’ intention to leave, χ2(1) = 5.35, p = 0.02.Conclusion:The results of this study add to the understanding of moral distress in pediatric nursing. Caring for victims with fatal maltreatment impacts pediatric nurses’ intention to leave. (shrink)

Background: Intensive care unit nurses are providing care to COVID-19 patients in a stressful environment. Understanding intensive care unit nurses’ sources of distress is important when planning interventions to support them. Purpose: To describe Canadian intensive care unit nurse experiences providing care to COVID-19 patients during the second wave of the pandemic. Design: Qualitative descriptive component within a larger mixed-methods study. Participants and research context: Participants were invited to write down their experiences (...) of a critical incident, which distressed them when providing nursing care. Thematic analysis was used to analyze the data. Ethical considerations: The study was approved by the ethics committee at the researchers’ university in eastern Canada. Results: A total of 111 critical incidents were written by 108 nurses. Four themes were found: (1) managing the pandemic, (2) witness to families’ grief, (3) our safety, and (4) futility of care. Many nurses’ stories also focused on the organizational preparedness of their institutions and concerns over their own safety. Discussion: Nurses experienced moral distress in relation to family and patient issues. Situations related to insufficient institutional support, patient, and family traumas, as well as safety issues have left nurses deeply distressed. Conclusion: Identifying situations that distress intensive care unit nurses can lead to targeted interventions mitigating their negative consequences by providing a safe work environment and improving nurses’ well-being. (shrink)

Layers of complexity arise when a person arrives in an Intensive Care Unit (ICU) due to self-harm intended to end their life and when there is known past personal trauma. We highlight three importa...

Megan1 is a young teenage patient who suffered a stillbirth at 28 weeks, leading to a year long police investigation dropped only after postmortem tests found that her pregnancy was lost due to natural causes. The stress of the investigation and her isolation from friends and support network following the seizure of her mobile and laptop compounded the trauma of the stillbirth, leaving her requiring emergency psychiatric care. Aisha1 is a vulnerable patient who suffered a premature delivery, having (...) experienced similar problems in earlier pregnancies. Things happened so quickly that Aisha delivered on her own at home, only then seeking medical care. She told hospital staff that earlier in her pregnancy she had considered an abortion. As a result, she found herself interviewed under police caution and was required to surrender her phone and tablet, limiting access to friend and family support just when most needed. Aisha was denied unsupervised access to her baby in the intensive care unit, needing to hand over expressed breast milk to a receptionist. These stories, which were reported in a recent meeting in Parliament,1 are sadly far from unusual. They reflect the collateral damage of a growing trend towards more enthusiastic enforcement of the archaic abortion laws of England and Wales.2–5 In such cases, women who present with miscarriage, stillbirth or a premature delivery have aroused the suspicion of health professionals, sometimes because—like Aisha—they speak honestly about having considered abortion earlier in their pregnancies. They then find themselves reported to the police, required to surrender electronic devices and sometimes advised by duty solicitors to speak to no one about events leading to their investigation, thus being denied emotional and full clinical support at a time of significant trauma. These women are not the only victims of British abortion laws: so …. (shrink)

Background: Patients with a traumatic injury often require intensive care for life-saving treatments. Physical suffering and emotional stress during critical care can be alleviated by ethical caring provided by nurses. The relationship between body and self are fundamentally inseparable. Nurses need to understand the impacts of traumatic injury on a patient’s body and self. Aim: To understand the meaning of traumatic injury for body and self for patients receiving intensive care. Research design: A qualitative descriptive (...) study using Giorgi’s phenomenological approach. Participants and research context: Patients receiving intensive care for physical trauma were selected by purposive sampling (N = 15) from a medical center in Taiwan. Individual in-depth, face-to-face audiotaped interviews, guided by semi-structured questions, were used to collect data. Each interview lasted 30–60 min. Audiotaped interviews were transcribed and analyzed. Ethical considerations: This study was approved by the Institutional Review Board of the medical center. Findings: The impact of the experience of traumatic injury on participants’ body and self was described by three main themes: (1) Searching for the meaning of the injured body, (2) Feeling trapped in the bed, and (3) The carer and the cared-for. Discussion and conclusion: The implications of the three themes described in the findings are as follows: Trauma as a source of meaning; Body and self are mutually limiting or mutually enabling; and Ethical relationships. The experience of needing intensive care following a traumatic injury on the body and self was dynamic and mutual. The experience of the injury changed the relationship between body and self, and gave new meaning to life. Nurses play a crucial role in continuity of care by understanding the meaning of a traumatic injury for patient’s body and self that facilitates ethical care and recovery from injury. (shrink)

Two pediatric accidents in Jane Austen’s Persuasion and one in Margaret Oliphant’s The Doctor’s Family are examined from the point of view of trauma management with analysis of contributing risk factors, medical management, concerns of parents and bystanders, and course of recovery. Risk factors for injury are impulsivity, poor supervision, and parents who are unable to set limits. Medical attention is swift and competent, but no heroic measures are used; the management of the injuries, concussion with loss of consciousness (...) and dislocation of the collar bone, is consistent with the way these conditions are, for the most part, still managed today, and successful recovery depends on careful nursing and rest. Louisa Musgrove, who suffers a severe head injury, requires ten weeks of convalescence and undergoes a marked personality change, which we might today attribute in part to post-concussion syndrome but which may reflect contemporary debate about the biological basis of personality and behavior. A sudden traumatic injury to a child or adolescent changes the narrative abruptly, in fiction or in life, dividing a story into before and after, introducing grief and anxiety, and requiring that plans be rethought and personal relationships reshuffled with decisions about caretaking and nursing. (shrink)

This secondary analysis re‐examined stories of caregiving told by NICU nurses in the southeast US through a trauma theory lens expanding on research surrounding substance‐exposed pregnancies. Narrative analysis identified distress‐related experiences of nurses related to child custody decisions and outcomes, suggesting traumatic stress within this caregiving dynamic. Four distinct story types and three themes were identified across 23 stories, highlighting similarities and differences and illustrating how distress and trauma were experienced and may be manifested in care practices. (...) Study findings suggest cumulative and residual effects from traumatic experiences can impact NICU nurses' well‐being and care provision, in part by promoting anticipatory trauma. The role of relationship‐building with families, as part of family‐centered care, was also implicated in the intensity of distressful experiences and may increase nurses' vulnerability to trauma as well as create pathways to stigmatizing interactions. Incorporating principles of relational ethics into nurse practice guidelines, while recognizing how care work can influence and be influenced by the potential pathways from trauma to stigma, may provide valuable support for nurses. The application of such a framework could potentially reduce distressing and/or traumatic experiences for nurses caring for families with a substance‐exposed pregnancy. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:More Than Words:Communicating for the Quality of CareElaine HsiehMy first experience as a healthcare interpreter was in the summer of 1998. I just completed the first year of a two-year graduate program in one of the top MA programs for conference interpreters—many of the graduates ended up working at the United Nations and international agencies. Many of my classmates chose to work in top business or government agencies for (...) their summer internships. I wanted to do something different. Something that I may never cross paths with again if I miss the opportunity. So, I chose to work as a healthcare interpreter intern at a large healthcare system. The summer internship was supposed to be a refreshing break from the drudgery of rigorous training to be a conference interpreter at an international level.As a graduate student who has received one year of intensive practicum training, I was proud of my "overqualification." At that time and to this day, the norm for most training programs for professional healthcare interpreters is a 40-hour short course (e.g., Bridging the Gap). With my advanced training and language proficiency, I thought this would be a fun, easy detour in my career development. I was excited to work with real people, no longer trapped in the isolating interpreting booths with headphones in conference rooms.Little did I know that the summer internship would change my life and career trajectory. The first big jolt that challenged my confidence as an interpreter was also one of the first assignments I received. I was taking an elderly man to his first physical therapy session. The man had such severe scoliosis that he was essentially looking backward as he walked forward. As we walked into the clinic, a medical resident saw my patient and jumped up in excitement. With a great smile on his face, he exclaimed, "Wow! This is the worst case I have ever seen." I felt startled. I could see that the patient was unsure about the resident's excitement. Normally, I would just go ahead and interpret what the physician said. I would then introduce the patient to the physician, explain my role as an interpreter (e.g., "I will interpret everything you and the patient say so you understand each other"), and proceed to interpret what other speakers said.However, all my training as an interpreter failed me at that moment. It's not because I was unsure about the linguistic equivalences of the resident's comment in Chinese. Rather, I was unsure how to best convey the information in a faithful, neutral, and accurate way without risking the provider-patient relationship and the quality of care. I explained to the physician, "Hi, my name is Elaine, and I am the healthcare interpreter. I am responsible for helping the patient understand what others are saying." Then, I asked, "How would you like me to interpret what you just said? You appeared very excited." The resident was taken aback, paused for a moment, and said, "Please tell him that I'm very happy to meet him." I interpreted that and proceeded to my regular routines.Another memorable moment took place at the end of a long shift near the end of my summer internship. I was already packing up to head home when I received a call to assist a 90-year-old patient who had just been admitted to a mental health ward after a failed suicide attempt a few hours ago. As an interpreter, I was required to interpret everything in the first-person style. For example, instead of saying, "The patient is sad," I say, "I am sad." Whenever possible, I also embody the speaker's nonverbals, including attitudes and emotions, through my interpretation. During the intake, the physician asked, "From 1 to 10, 1 being the least happy day in your life and 10 being the happiest, what number do you feel right now?" With the emptiest stare and the most soulless voice, the patient said, "If I have never experienced happiness in my life, how [End Page 159] do I know which number to give?" Throughout the hour-long session, I spoke in the... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Echoes of Grief:Tales from an Emergency Medicine and Critical Care NurseMarcia KingWell, I have 42 years of stories from working in ICU and Emergency Medicine as a registered nurse. The first situation that comes to mind on the subject of grieving on the job in healthcare happened about 37 years ago. I had a nice lady in ICU for several days in a row as a patient. She (...) had a bad myocardial infarction (MI) and was critical. We tried all the medications and pain meds, and nothing took her chest pain away. Meanwhile, her husband stayed with her all day, and all night. He doted after her 24/7. He slept in a chair and never went home for about three days, even though they lived just a few blocks from the hospital. I was amazed at what an awesome husband he was.Finally, after about three days, she fell asleep for more than 10 minutes. She had said her pain was gone. Her husband didn't want to leave her, but he asked me "if it would be okay" to go home and take a shower, eat a sandwich, and get the mail. He explained that he would be right back.I said, "Sure, now is a good time since her pain is gone and she's sleeping. You must take care of yourself too."The husband ran out in a hurry. About 10 minutes after he left, his wife suddenly had pain again and a run of ventricular tachycardia, (V-tach), which is a type of abnormal heart rhythm, or arrhythmia. Even though the V-tach stopped on its own, I called the husband and told him to come back because he wanted to be there if anything happened. A few minutes later, she had another run of V-tach, but this time, she coded and died. About two minutes after she died, the husband came running into the room—panicked and crying and talking to her dead body.He was saying, "I'm so sorry I left you! I shouldn't have left you!" I felt awful because I was the one who told him it was okay to go. Then I was crying with him and for the poor man.He then left for home, and their doctor (who was a well-known grouch-ass) appeared and saw that I was upset, and he asked me what my problem was. Why was I so sad about it? I thought, "Jerk, you are in the wrong career."Thinking about that doctor's reaction at the time, I wondered, "WTF is wrong with him!" I had known the doctor for several years because his mom was the head nurse of the surgical floor. I thought for a moment and then said to him, "How could you be a decent doctor if that death didn't bother you?" I was [End Page 74] in my 20s at the time—a fairly new nurse—and was just starting to be able to feel comfortable speaking up and being assertive.I just felt so bad for that poor man. I felt terrible that I told him it was okay to run home. He really wanted to be there if something happened to her, and from what I saw, he was an amazing husband to her. Looking back, she probably was waiting for the minute he stepped out to go.Another time, while working in the emergency department, a trauma alert was called on a patient who came in by ambulance. We were told the woman had fallen off a hayloft while pushing hay onto the floor in her barn. She hit her head bad in the fall. She wasn't my patient, but I ran into the room to help when she arrived. There was a bunch of staff around blocking my view. Without even looking at her, I grabbed her arm to put in an IV as I had done thousands of times before. Suddenly, I noticed it was weirdly quiet. I looked up, and the ER Doc and tech were looking at me funny. Then the Doc said, "Marcia, you know who this is, don't... (shrink)

Intensive care units are not always able to admit all patients who would benefit from intensive care. Pressure on ICU beds is likely to be particularly high during times of epidemics such as might arise in the case of swine influenza. In making choices as to which patients to admit, the key US guidelines state that significant priority should be given to the interests of patients who are already in the ICU over the interests of patients (...) who would benefit from intensive care but who have not been admitted. We examine four reasons that in principle might justify such a prioritization rule and conclude that none is convincing. We argue that the current location of patients should not, in principle, affect their priority for intensive care. We show, however, that under some but not all circumstances, maximizing lives saved by intensive care might require continuing to treat in the ICU a patient already admitted rather than transferring that patient out of the unit in order to admit a sicker patient who would also benefit more from intensive care. We conclude that further modelling is required in order to clarify what practical policies would maximize lives saved by intensive care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Cracked ArmorJoanne AlfredDisclaimers. Names have been changed to protect the privacy of the patient and the patient's family.After three weeks of night shifts, I had built a routine of driving home in darkness and watching the sunrise. It had become my way to push back against a quiet melancholy, the accumulation of loss over time, by remembering that light gently returning each morning. Heading into my last stretch of (...) ten nights in a row, I was intent to hold to this practice, to anchor myself for the challenge. The one-and-a-half years of residency training had prepared me for these moments, opportunities to grow and persist. The first six days of the stretch passed as I had expected, and the confidence and autonomy I had cultivated carried me through. It always had. I had shouldered our neurosurgery service, solitary night shifts at community hospitals, the NICU. I had pronounced a newborn dead on Good Friday, heartbroken by the juxtaposition of life and death. My experiences allowed tears and doubts, but I had always rebounded, chin up and looking onward for the next thing.I had just received sign out, and needed to check on Nate, a young man I'd known since he was first diagnosed with T-cell acute lymphoblastic leukemia (T-Cell ALL). I remembered our first meeting, a new diagnosis with a white cell count in the thousands requiring PICU admission for plasma exchange, all the way to reassuring him his EKG was normal after an incidental finding of hyperkalemia. He had returned to the hospital with abdominal swelling, and dread filled me as I rounded the corner to his room. Looking down at him and back up at his mother, my own distress reflected in their eyes. We needed help. I quickly found the oncology fellow and attending, and we put our heads together, deciding a blood gas and X-ray would be the next best steps. The results confirmed our suspicions.Nate was transferred to the PICU shortly. I watched his mother console him, remembering how much they both disliked the PICU. It was not a [End Page 85] place of pleasant memories, especially as Nate had been working toward remission therapy rather than returning to the intensive care unit, where he fought through his initial diagnosis. While reassuring him and his mother externally, internally my own dread welled further, because my first night in the PICU loomed two days away. To bolster myself for my seventh night shift, I rounded with the PICU team to learn as much as I could. Nate was on BIPAP now, and the decision inexorably moved to intubation. It was all happening rapidly, and the dread started feeling more like panic. Nate's eyes were squeezed shut, his stomach taut, and his breathing shallow. I truly worried for Nate now. I had hoped the PICU would be a temporary stay, a place where we could make a diagnosis and fill the gap. However, when I joined the private conversation the PICU attending had with Nate's mother and she said, "He may never come off the ventilator. He may never speak again," the finality in her voice had more certainty.The "never" struck my brittle residency armor and it cracked. I was not ready to believe it. I could sense his mother felt the same, so we walked along the silent halls of the hospital while she remembered Nate with me as a teenage boy beyond the hospital, not as his ascites and acidosis. Maybe to make his turn for the worse untrue. But I knew something awful was going to happen.On my eighth night, I entered the PICU with trepidation. All I could think about was Nate. He was now on dialysis, struggling with true hyperkalemia. Turning the corner to the unit, my heart racing, begging please don't let him die. It was hard to sense in the moment, but the cumulative melancholy, the sense that it could be held back, was not holding true. So, I defaulted to my splintering armor of persistence, picking apart his labs, discussing his dialysis with the nephrology fellow. I put my head down... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Night ShiftCalvin R. GrossI don't like working at night anymore. Too much goes wrong when you're alone.I'm sitting at my desk in the middle of the cardiac intensive care unit, and it's far later than I'd like to be awake—two or three in the morning. Things are calm, almost pleasant. I can hear the occasional alarm going off—an imperfectly positioned blood pressure cuff, a pulse oximeter with (...) a poor waveform, a ventilator with secretions in it. The night's initial frenzied work is done; my new admissions are tucked away, and my overnight to-dos are completed. Now it's just time to sit and wait. I could sleep, but despite the calm, I'm too afraid to leave the unit to rest. The fellow has gone to bed hours ago, and now it's just me. Sure, I'm surrounded by experienced nurses who know their work well, but somehow, I'm the one in charge. A brand-new second-year resident, the only doctor there. I'm no intern, that's for sure, but I've never led a code before, and I've only ever placed one central line without supervision. As second years go, I'm as fresh as they come.The daytime, you see, is far different than nights. There's a large (and even bloated) team of two attendings, two fellows, two pharmacists, and more importantly, multiple other residents. When you don't know what to do for a patient, there's always someone there to bounce ideas off of. When something difficult or surprising happens, there are peers and mentors to process with. At night, it's the opposite—no peers, no mentors, only a group of experienced nurses, whose circle is closed to me, the outsider. I long to be a part of that large and bloated daytime team."Can you come into 23? I think his pupils are a different size."I'm startled out of my thoughts. 23 … All I can remember from sign-out that evening is that he's young, close to my age, and supposedly stable. I look at my notes, a catalogue of tragedies: early onset heart failure, multiple prior suicide attempts, intubated because of pulmonary edema, and a left-ventricular assist device (LVAD) that's malfunctioning. I walk over to the room and look at the nurse at the other side of the bed. She's in the early phases of her career too—less than a year on the job—but she's still more experienced than me. I take a flashlight, open his eyelids, and look at the pupils. Sure enough, one of them is much larger than the other. When I shine the light into each eye, the large one doesn't change. When I turn his head from side to side, his eyes stay fixed. We look [End Page 83] at each other, she and I. We both know something terrible is happening."Should we maybe wake the fellow up?" she asks tentatively.I nod my head in agreement, glad to have been offered a suggestion. It's the right thing to do. I walk to the fellow's call room, knock on the door, and wake him up. He's set to work 24 hours and would like nothing more than to keep resting. He sleepily comes with me to the bedside, looks at the pupils as well, and says, "With the sedation on, your exam isn't going to be the most accurate. We should start by scanning his head, and then go from there. Wake me back up if you need me, but I know you've got this one."I don't think that I deserve the confidence he has in me. I walk back to my desk, open the patient's chart, and place the order for an urgent CT scan. The machinery of the hospital starts to rumble as the imaging schedulers find a spot in the queue for the scan, the patient's nurse and respiratory therapist disconnect and reconnect cables and tubes, the technicalities of the scan are ironed out, and he is... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The 12–Minute JourneyHeather A. CarlsonI met Jack for the first time when he was in the intensive care unit as he was just waking up from his emergent tracheostomy surgery. As I walked into his room he opened his eyes in panic and he struggled to take in a deep breath, fighting the ventilator that was trying to deliver slow steady breaths for him. His face was (...) flooded with fear and the ventilator alarms were blaring. He was surrounded by nurses and respiratory technicians all trying to calm him down, while adjusting the settings on the machine. “Just try and breathe slowly,” they instructed him, though this seemed to be impossible for him as he continued to try and suck in as much air as possible through the new hole in his throat. As his arm flailed out I grabbed his hand and while holding it in mine I just tried to emulate tranquility for him. I thought to myself this is exactly how I would react if I woke up in this condition and could imagine the fear that he was now feeling. While nurses rushed around with suction equipment and the respiratory technicians made adjustments and monitored the results I stood there holding his hand silently praying that he become calm. With all of our support he did eventually relax and find the ability to sync his breathing with the ventilator settings.I am a palliative care nurse practitioner and had been asked to see Jack to help with symptom management and establishing his goals of care as he had recently been diagnosed with head and neck cancer. He had presented to the hospital with complaints of difficulty breathing and it didn’t take long for the emergency room physician to determine that his airway was almost completely occluded by tumor. Jack had actually been diagnosed with this cancer the month before, and had met with a radiation oncologist who planned to start radiation as soon as possible to avoid tumor growth that could impair his breathing. Unfortunately Jack was so anxious and scared about this treatment plan that he never went back to the cancer center. Instead, he stayed in his room in the boarding house that he lived in, smoking cigarettes to calm his nerves. Jack was a recovering alcoholic who had previously been homeless and out on the streets for many years before becoming sober and finding shelter at the boarding house where he now lived. He was a heavy smoker and found that it was one thing that helped to ease his anxiety. The thought of being strapped down to a table with a tight mask over his head while radiation zapped the cancer in his neck had terrified him. His anxiety and claustrophobia had prevented him from following through with his cancer treatment.My initial visits with Jack were spent trying to treat his anxiety as well as the pain he experienced in his neck and head.Because he had undergone a tracheostomy and was now on a ventilator he was unable to speak. To communicate he pointed to a picture board that had common sayings on it, like “I have pain” and “I have to go to the bathroom”. He also used a clipboard with paper and pen and could write what he wanted to say, but this was a time consuming endeavor. Despite this, he was a very animated gentleman who had a lot to say and he wasn’t going to let the loss of his voice impair him. I found myself enjoying my visits with him each day, as he would tell me more about himself. I quickly discovered that he was a very spiritual man and his faith was his inspiration. He wrote on his clipboard “this cancer is actually a gift” and went on to explain that he had been on a fast track toward self destruction, but now feels as though he has been given another chance at life. He spent his time in the hospital reflecting on his life’s journey and how he would be able to help others in similar circumstances. He wrote on his [End Page 192] clipboard multiple... (shrink)

Severe Traumatic Brain Injury (TBI) remains a major cause of death and disability afflicting mostly young adult males and elderly people, resulting in high economic costs to society. Therapeutic approaches focus on reducing the risk on secondary brain injury. Specific ethical issues pertaining in clinical testing of pharmacological neuroprotective agents in TBI include the emergency nature of the research, the incapacity of the patients to informed consent before inclusion, short therapeutic time windows, and a risk-benefit ratio based on concept that (...) in relation to the severity of the trauma, significant adverse side effects may be acceptable for possible beneficial treatments. Randomized controlled phase III trials investigating the safety and efficacy of agents in TBI with promising benefit, conducted in acute emergency situations with short therapeutic time windows, should allow randomization under deferred consent or waiver of consent. Making progress in knowledge of treatment in acute neurological and other intensive care conditions is only possible if national regulations and legislations allow waiver of consent or deferred consent for clinical trials. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:“It’s All Personal”Frances Rieth MaynardI was (am?) the mother of a full-term infant born in 1998 with hypoplastic left heart syndrome. This was my 3rd pregnancy; I had two prior pregnancies resulting in healthy children. Until that final week before birth, my pregnancy had been uneventful; my blood pressure, weight gain, and lab work charted normally. At my prenatal check (with a new physician as mine was away), my (...) measurements were off. That OB-GYN referred me to a perinatologist who was able to perform an ultrasound (checking for infant size) and advised that I should deliver soon because the infant was markedly growth retarded. I was induced two days later. My small daughter was born with skeletal leg deformities and brought to the neonatal intensive care unit (NICU). I was familiar with that NICU since I had worked there as an RN prior to this pregnancy. I was comfortable with the environment, the people, and the overall culture of the place. Indeed, I had been a pediatric nurse for the previous 10 years working primarily in intensive care.After my daughter’s birth, I was able to intuit meaning by the placement of her bassinet in the unit (e.g., it was not too close to the nurse’s station; she had no oxygen or tubing, and she was not in a private room). I believed that her journey home would be longer than I had planned but that it would occur. On that first day, a pediatric cardiolo-gist arrived to perform an ultrasound. I was familiar with this scene too; I did not view this process as anything more than routine. I was relieved to have [End Page 24] a physician who I knew and trusted to watch over my daughter. This allowed me to go back to my room to rest as I do not believe I had slept well (if at all) after being informed there was a potential problem a few days earlier.Less than two hours after returning to my room, my daughter had been intubated and begun on prostaglandins as the echocardiogram had revealed a hypoplastic left heart defect. The neonatologist started to discuss options for transport so my daughter could be treated at a larger hospital. I tried to catch my breath and process what I was being told. We spoke by phone with my husband who quickly deferred all decision-making responsibility to me because I was “the person with the medical expertise.” My thoughts raced with all these unforeseen circumstances, yet time seemed to slow down. I requested that an evaluation be made of other potential conditions before transfer since my daughter was also small for gestational age, something we had learned less than a week earlier, and she had some skeletal defects, an issue of which we were unaware until after she was born.A head ultrasound revealed an absent corpus callosum, the region of the brain that connects the two cerebral hemispheres and allows them to communicate by sending and receiving signals from each other.Given all the enormous medical issues my daughter was facing, I asked for her ventilator to be withdrawn and my husband concurred. We wanted our daughter to be baptized and to die a “natural death.” Our neonatologist indicated that our choices were reasonable. But, before the ETT could be withdrawn, I was advised that an ethics consult had been called by one of the nurses. I became angry, scared, and saddened at the thought of strangers (to me) deciding the fate of my daughter. The neonatologist told me not to be concerned, and I later learned that the ethics committee had “signed off” on the wishes of my husband and myself. My daughter was extubated and died 3 days later.This happened 25 years ago. In retrospect, it is interesting to me that I began to distrust the nurses, wondering which one had called the consult. I could not understand how anyone could doubt that I, as a mother, was not making the best possible decision, among bad alternative choices, for my daughter. I began to view the anonymous persons of the powerful ethics committee as a “them... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Don't Mute the MessengerNilsa RicciAs a Spanish interpreter, I spend a lot of time talking with patients, family members, and other care team members. Like how an actor reciting from never-before-seen cue cards is talking or how a medium in a trance during a séance is talking. I talk without my voice. This leaves a lot left unsaid.I am also a resident, and I communicate with patients, family (...) members, and other care team members in my own words. Working as both a Spanish interpreter and resident has given me a unique perspective, particularly about the boundaries I am able to set with patients. Both Spanish interpreters and medical providers are expected to maintain a professional distance with patients, which can [End Page 171] provide a certain level of emotional protection. However, the nature of interpreting compromises this distance and protection.In first person I must speak,Which makes my position unique.I was taught to interpret everything in the first person. For example, instead of saying, "The patient's mother is asking if her baby is dead …?" I ask, "Is my baby dead?!" The intent is to facilitate direct communication between patients and providers so they can build rapport. Unnoticed is that I hear a patient's traumatic experience, process it, and then deliver those vivid details in the first person of another language. My sense of self is breached because the first person is no longer innately reserved for my own self. The topic does not even have to be traumatic in the typical sense for it to cause harm. Speaking in the first person erodes the boundaries between self and non-self, exposing me to emotional trauma.One day, I was paged to an intensive care unit to interpret for a doctor and mother in front of an unconscious person on a ventilator. I had to play the role of a doctor who desperately wants to convince a mother that her son has no chance of survival—I must directly challenge any hope for a miracle to spare her a long road of heartbreak and disappointment. I also had to play the role of a mother who strongly questions science—I know faith is essential to my son's recovery, and I will wait for a miracle.In breaking bad news, there is that heavy moment when hopeful eyes beg for anything other than the painful message about to be delivered. The words may not be mine in origin, but the reaction is always to my interpretation. I watch the light of hope dull into despair and observe life leave the mother's essence.Boundaries blur as I play each part:I lend my voice but sacrifice my heart.Suddenly, I am wearing the mother's shoes and we experience grief's abyss together. I am made to recount memories I had with my son and made to long for the ones we will never form. Tears obscure my vision, and I feel my heart break as I realize my son is dead. My world crumbles and my vocal cords quiver then halt. I know the next sound will be incomprehensible. Wailing, the mother's voice is only intermittently understandable. In Spanish, she exclaims, "How many years must I live without you?" The doctor looks at me, inquisitive of my new silence.False memories flood my brainAs if possessed by pain.I hear myself say, "I can't understand her exactly," and then summarize her words in the third person. Instantly, I feel some relief. But with the relief comes shame for showing my weakness—for needing to break the protocol to cling to my sense of self. My pager suddenly beeps, breaking through the confusion like an alarm clock interrupting a nightmare. In a daze, I remember I am the interpreter—not this doctor, not this mother. I do not have a patient with complete loss of brain function. I do not have a son to bury. The doctor says, "Let's give her some privacy," and we excuse ourselves from her grief.Why then are your shadows still in sightEven now that my own script I write... (shrink)

New parents suddenly come face to face with myriad issues that demand careful attention but appear in a context unlikely to provide opportunities for extended or clear-headed critical reflection, whether at home with a new baby or in the neonatal intensive care unit. As such, their capacity for autonomy may be compromised. Attending to new parental autonomy as an extension of reproductive autonomy, and as a complicated phenomenon in its own right rather than simply as a matter to (...) be balanced against other autonomy rights, can help us to see how new parents might be aided in their quest for competency and good decision making. In this paper I show how a relational view of autonomy – attentive to the coercive effects of oppressive social norms and to the importance of developing autonomy competency, especially as related to self-trust – can improve our understanding of the situation of new parents and signal ways to cultivate and to better respect their autonomy. (shrink)

BackgroundPrognostic uncertainty is a challenge for physicians in the neuro intensive care field. Questions about whether continued life-sustaining treatment is in a patient’s best interests arise in different phases after a severe traumatic brain injury. In-depth information about how physicians deal with ethical issues in different contexts is lacking. The purpose of this study was to seek insight into clinicians’ strategies concerning unresolved prognostic uncertainty and their ethical reasoning on the issue of limitation of life-sustaining treatment in patients (...) with minimal or no signs of neurological improvement after severe traumatic brain injury in the later trauma hospital phase.MethodsInterviews with 18 physicians working in a neurointensive care unit in a large Norwegian trauma hospital, followed by a qualitative thematic analysis focused on physicians’ strategies related to treatment-limiting decision-making.ResultsA divide between proactive and wait-and-see strategies emerged. Notwithstanding the hospital’s strong team culture, inter-physician variability with regard to ethical reasoning and preferred strategies was exposed. All the physicians emphasized the importance of team—family interactions. Nevertheless, their strategies differed: (1) The proactive physicians were open to consider limitations of life-sustaining treatment when the prognosis was grim. They initiated ethical discussions, took leadership in clarification and deliberation processes regarding goals and options, saw themselves as guides for the families and believed in the necessity to prepare families for both best-case and worst-case scenarios. (2) The “wait-and-see” physicians preferred open-ended treatment (no limitations). Neurologically injured patients need time to uncover their true recovery potential, they argued. They often avoided talking to the family about dying or other worst-case scenarios during this phase.ConclusionsDepending on the individual physician in charge, ethical issues may rest unresolved or not addressed in the later trauma hospital phase. Nevertheless, team collaboration serves to mitigate inter-physician variability. There are problems and pitfalls to be aware of related to both proactive and wait-and-see approaches. The timing of best-interest discussions and treatment-limiting decisions remain challenging after severe traumatic brain injury. Routines for timely and open discussions with families about the range of ethically reasonable options need to be strengthened. (shrink)

Researchers have identified the phenomena of moral distress through many studies in Western countries. This research reports the first study of moral distress in Iran. Because of the differences in cultural values and nursing education, nurses working in intensive care units may experience moral distress differently than reported in previous studies. This research used a qualitative method involving semistructured and in-depth interviews of a purposive sample of 31 (28 clinical nurses and 3 nurse educators) individuals to identify the (...) types of moral distress among clinical nurses and nurse educators working in 12 cities in Iran. A content analysis of the data produced four themes to describe the nurses’ moral distress. The four themes were as follows: (a) institutional barriers and constraints; (b) communication problems; (c) futile actions, malpractice, and medical/care errors; (d) inappropriate responsibilities, resources, and competencies. The results demonstrate that moral distress for intensive care unit nurses is different and that the nursing leaders must reduce moral distress among nursing in intensive care. (shrink)

Background Patient dignity is sometimes neglected in intensive care unit (ICU) settings, which may potentially cause psychological harm to critically ill patients. However, no instrument has been specifically developed to evaluate the behaviors of dignified care among critical care nurses. Aim This study aimed to develop and evaluate ICU Dignified Care Questionnaire (IDCQ) for measurement of self-assessed dignity-conserving behaviors of critical care nurses during care. Methods The instrument was developed in 3 phases. Phase (...) 1: item generation; phase 2: a two-round Delphi survey and a readability pilot study; phase 3: cross-sectional survey with model estimation. The questionnaire was evaluated by item analysis, exploratory and confirmatory factor analysis, assessment of internal consistency reliability, and test-retest reliability. The investigation was conducted using a convenience sample of 392 critical care nurses from 6 cities in Zhejiang Province, China, of which 30 participated in the test-retest reliability survey 2 weeks later. Ethical considerations The study was approved by ethics committee. All participants provided written informed consent before the survey. The questionnaire survey was anonymous. Results The results showed acceptable reliability and validity of the IDCQ. The 17-item final version questionnaire was divided into 2 dimensions: absolute dignity and relative dignity. These two factors accounted for 62.804% of the total variance, and model fitting results were acceptable. The Cronbach’s alpha coefficient of the questionnaire was 0.94, and the test-retest intraclass correlation coefficient (ICC) was 0.88 after 2 weeks. Conclusions This study developed a brief and reliable instrument (IDCQ) to assess dignified care in ICU nursing. It can help critical care nurses identify their behaviors in maintaining patient dignity and discover their deficiencies. It may also serve as a clinical nursing management tool to help reduce patient disrespect experience in ICU. (shrink)

In May 2011, the clinical ethics group of the Center for Ethics at Washington Hospital Center launched a 40-hour, three and one-half day Clinical Ethics Immersion Course. Created to address gaps in training in the practice of clinical ethics, the course is for those who now practice clinical ethics and for those who teach bioethics but who do not, or who rarely, have the opportunity to be in a clinical setting. “Immersion” refers to a high-intensity clinical ethics experience in a (...) busy, urban, acute care hospital. During the Immersion Course, participants join clinical ethicists on working rounds in intensive care units and trauma service. Participants engage in a videotaped role-play conversation with an actor. Each simulated session reflects a practical, realistic clinical ethics case consultation scenario. Participants also review patients’ charts, and have small group discussions on selected clinical ethics topics. As ethics consultation requests come into the center, Immersion Course participants accompany clinical ethicists on consultations. Specific to this pilot, because participants’ evaluations and course faculty impressions were positive, the Center for Ethics will conduct the course twice each year. We look forward to improving the pilot and establishing the Immersion Course as one step towards addressing the gap in training opportunities in clinical ethics. (shrink)

This research aims to identify the ethical issues perceived by intensive care nurses in their everyday practice. It also aims to understand why these situations were considered an ethical issue and what interventions/strategies have been or are expected to be developed so as to minimize them. Data were collected using a semi-structured interview with 15 nurses working at polyvalent intensive care units in 4 Portuguese hospitals, who were selected by the homogenization of multiple samples. The qualitative (...) content analysis identified end-of-life decisions, privacy, interaction, team work, and health-care access as emerging ethical issues. Personal, team, and institutional aspects emerge as reasons behind the experience of these issues. Personal and team resources are used in and for solving these issues. Moral development and training are the most significant strategies. (shrink)

Background Moral distress is a serious problem for health care personnel. Surveys, individual interviews, and focus groups may not capture all of the effects of, and responses to, moral distress. Therefore, we used a new participatory action research approach—moral conflict assessment (MCA)—to characterize moral distress and to facilitate the development of interventions for this problem. Aim To characterize moral distress by analyzing responses of intensive care unit (ICU) personnel who participated in the MCA process. Research Design In (...) this qualitative study, we invited all ICU personnel at 3 urban hospitals to participate in individual or group sessions using the 8-step MCA tool. These sessions were facilitated by either a clinical ethicist or a counseling psychologist who was trained in this process. During each session, one of the researchers took notes and prepared a report for each MCA which were analyzed using qualitative content analysis. Participants and Research Context A total of 24 participants took part in 15 sessions, individually or in groups; 14 were nurses and nurse leaders, 2 were physicians, and 8 were other health professionals. Ethical Considerations This study was approved by the Providence Health Care/University of British Columbia Behavioural Research Ethics Board. Each participant provided written informed consent. Results The main causes of moral distress related to goals of care, communication, teamwork, respect for patient’s preferences, and the managerial system. Suggested solutions included communication strategies and educational activities for health care providers, patients, family members, and others about teamwork, advance directives, and end-of-life care. Participants acknowledged that using the MCA process helped them to reflect on their own thoughts and use their moral agency to turn a distressing situation into a learning and improvement opportunity. Conclusions Using the MCA tool helped participants to characterize their moral distress in a systematic way, and to arrive at new potential solutions. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:My StoryDawn Ruggeroli–CollinsMy story starts on October 17, 1981. I was 17–years–old and was riding home from a night with friends at the Roundup Rodeo in Simonton, Texas. The girl who was driving was a friend of a friend, so unfortunately I did [End Page E5] not know her well enough to realize that she was drunk. I have very little recollection of the accident, nor of the few (...) days that followed. However, I do recall being very aware that I was paralyzed.For some reason, I had for the previous few years been reading books by women who had spinal cord injuries as a result of some type of accident. I read Joni Eareckson’s book “Joni” and “The Other Side of the Mountain” about Jill Kinmont, and saw the movies about both women. Additionally, my mother bought me “Karen,” and “With Love, from Karen” the story of Karen Killalea, who has cerebral palsy. It seemed to me that reading these books prepared me for dealing with my disability in a positive way rather than “woe is me.”I’m actually one of the luckiest people you’ll ever know! While I have a C–4/C–5 SCI, it is pretty incomplete and as a result I’m pretty mobile. I wear an ankle–foot orthotic (AFO) on my right foot and use a cane. I do have Brown–Séquard syndrome, with better sensation on my right side and better function on the left. So, I was right–handed the first 17 years of my life and I’m now a leftie.A couple of days after my accident, while I was still in the intensive care unit (ICU), one of the nurses felt that it was important for me to realize that I would probably be paralyzed for the rest of my life; never to walk again. So she took it upon herself to deliver this message personally. Well, I wasn’t having any of that! I yelled and screamed and threw the biggest tantrum that one can throw while one’s head is clamped down by Gardner–Wells tongs. Given how well I have recovered, I have often thought how it would be to find Judy, walk up to her, and ask if she remembers me.My dad has often told me that he thinks I went through the grieving process pretty quickly after my accident. It wasn’t always easy, and I did have my down moments, but for the most part I think he’s right. I’ve always been a positive person and that helped get me through this and many other trying times in my life. I think at the time I also had a fear that no one would want to be around me if I was stuck in a wheelchair and was a Debbie Downer. I was only 17 after all.When I went away to college I was still mainly using a wheelchair. When I told a friend that I didn’t want to be in a dorm with all of the disabled students, she laughed and asked me why I didn’t want to be with “my people.” Aside from playing some wheelchair basketball, I had never really hung out with other people with disabilities. I was briefly involved with a disabled support type of group but many of them had really negative attitudes. I didn’t stick around for very long after I learned that one of the guys said to one of the women that she would be really attractive if it weren’t for “that wheelchair.” This coming someone in a wheelchair himself!During my second year at Michigan State I had my first realization that people don’t just see me as someone with a disability. A friend was talking with an acquaintance from the other side of our dorm and she mentioned me. The acquaintance said “oh, Dawn in the wheelchair?” and her response was “yeah, I guess she is in a wheelchair.” When she relayed this conversation to me later I was really moved that she didn’t see me as someone in a wheelchair first... (shrink)

Suffering repeated experiences of moral distress in intensive care units due to applications of futility reflects on nurses’ patient care negatively, increases their burnout, and reduces their job satisfaction. This study was carried out to investigate the levels of job satisfaction and exhaustion suffered by intensive care nurses and the relationship between them through the futility dimension of the issue. The study included 138 intensive care nurses. The data were obtained with the futility (...) questionnaire developed by the researchers, Maslach Burnout Inventory and Minnesota Satisfaction Questionnaire. It was determined that nurses who agreed to the proposition that the application of futility demoralizes health-care professionals had low levels of job satisfaction but high levels of depersonalization. It was determined that nurses had moderate levels of job satisfaction, emotional exhaustion, and personal achievements but high levels of sensitivity. Nurses’ job satisfaction and sensitivities are positively affected when they consider that futility does not contradict the purposes of medicine. (shrink)

Not only is deception commonplace in medical encounters, according to Christopher Meyers (2021), but the clinical ethicist might have moral obligations to support and even enact deception. Descriptively Meyers is right that there are “opportunistic, self-interested and benevolent reasons” for deception through omission and commission in clinical medicine. But it is possible to retain this premise while rejecting the normative conclusion that the clinical ethicist “should sometimes be an active participant in the deception of patients and families.” One reason to (...) reject the normative conclusion is its incompatibility with providing trauma informed ethics consultation (TIEC). In the TIEC framework I developed with Uchenna Anani, we defend the integration of trauma informed care (TIC) into ethics consultation (Lanphier and Anani 2021). While ethicists narrowly attend to the question and scope of the ethics consults made to them, doing so in alignment with trauma informed principles is tantamount to providing good ethics consultation. According to Meyers, the clinical ethicist is an “advocate for the best ethical choices.” The best ethical choices are also trauma informed ones. (shrink)

Suffering repeated experiences of moral distress in intensive care units due to applications of futility reflects on nurses’ patient care negatively, increases their burnout, and reduces their job satisfaction. This study was carried out to investigate the levels of job satisfaction and exhaustion suffered by intensive care nurses and the relationship between them through the futility dimension of the issue. The study included 138 intensive care nurses. The data were obtained with the futility (...) questionnaire developed by the researchers, Maslach Burnout Inventory and Minnesota Satisfaction Questionnaire. It was determined that nurses who agreed to the proposition that the application of futility demoralizes health-care professionals had low levels of job satisfaction but high levels of depersonalization. It was determined that nurses had moderate levels of job satisfaction, emotional exhaustion, and personal achievements but high levels of sensitivity. Nurses’ job satisfaction and sensitivities are positively affected when they consider that futility does not contradict the purposes of medicine. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:I Had Never Heard Someone Use That Word BeforeAdrienne Feller NovickThe patient was dying. As the social worker, I had arranged the meeting and sat shoulder to shoulder with the family and the attending physician in the small nondescript room. The family was grief-stricken and asked intelligent questions as they made difficult decisions about end-of-life care for their loved one. The doctor spoke with gentle kindness, acknowledging their (...) difficult decision as he completed the neon pink Medical Orders for Life Sustaining Treatment (MOLST) form and left the room. I was tangled up with emotions; I felt relieved that the meeting had gone smoothly, sad for the patient and family, and in awe of the doctor for his ability to lead the difficult conversation. I stayed behind to ask the family if there was anything I could do to help them. [End Page E4]Before I could speak, the patient's wife turned to me and said, "I am so glad that k--- left the room." (Using a derogatory word for a person of the Jewish faith). My brain began processing the statement. I am a Jewish woman. Did I hear that right? Did she say what I think she said? Should I say something? I froze, and time seemed to stop. She was looking at me expectantly, waiting for a response. Her face reminded me of someone waiting for the other person to return a "high five." I was flooded with emotion. A succession of thoughts ran through my head, everything from being rude in response or getting physical. I did neither. I said nothing. I smiled and left the room feeling like I had been gut-punched.I was in denial. I made excuses for the wife; she was stressed. I kept thinking I must not have heard her correctly and that I was overreacting. I continued to work with the family as though nothing had happened until the patient died five days later. I felt ashamed and never told anyone about what happened. I regretted not saying anything. I replayed the conversation in my mind and felt depressed and angry. Inside I felt complicit for not speaking up, but I had no words. I assumed bias in healthcare was rare. I did nothing.Years later, after I completed a patient visit in the Intensive Care Unit (ICU), I observed a group of surgical residents doing rounds. The attending welcomed me to join this valuable clinical learning experience. As the group approached the next bed, the patient pointed to one resident and loudly said, "I don't want a doctor who looks like that to come near me." I gasped aloud and froze, waiting to see what would happen next. The attending looked directly at the patient and said calmly, "We are all here to help you. That is not an appropriate thing for you to say." Then, he turned to the resident and nodded, directing them to resume their bedside assessment. The patient mumbled something inaudibly and said nothing.To my astonishment, the doctor acknowledged the microaggression (a microaggression is a statement, action, or incident regarded as discrimination), addressed the issue, respectfully supported the resident, created a safe space for everyone on the healthcare team and resumed quality patient care without missing a beat. He modeled a strategy to address patient bias and taught a valuable skill. This was a learning moment for me. It helped me refocus my past experience and provided me with a useful strategy to address bias in the future.As a member of the medical ethics consultation service, I listen, provide support, and aid in challenging communications. I had the opportunity to model the communication strategy I acquired in the ICU. The medical ethics team was consulted for a patient refusing treatment. The patient was disrespectful to healthcare team members, cursing at nurses and residents, using ethnic slurs, and saying he "would rather die than let one of them touch him. I entered the patient's room with the healthcare team, introduced myself, and explained the reason for my visit. The patient defiantly agreed he had used slurs, saying he wanted to go home. I continued, everyone here... (shrink)

Burnout is a well-documented entity in Care Workers population, affecting up to 50% of physicians, just as it is equally well established that managing an infectious disease outbreaks, such as confirmed in the COVID-19 pandemic, increases Post-Traumatic Stress Disorder and the psychological burden. Mental health support, in the form of formal or remote sessions, has been shown to be helpful to health care staff, despite the organizational difficulties in an emergency. During the first emergence of COVID-19 in Italy, (...) the Scientific Institute for Research, Hospitalization and Health Care Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo Foundation, the Italian hospital that treated “patient 1,” has activated an agreement with the Soleterre Foundation, an international Non-Governmental Organization that manages health emergency projects, to provide psychological support. A task force of psychologists was created with the aim of designing and administering a Therapeutic Mental Health Assessment for COVID-19 Care Workers to evaluate and support health care workers’ mental health. The assessment battery was developed to evaluate symptoms and behaviors associated with trauma and the corresponding maladaptive behaviors. Once the TMHA COVID-19 CWs had been developed, the team of psychologists regularly visited healthcare staff in the ward to administer it. One hundred seven care workers across Intensive Care Units, the emergency room and medical ward were administered the TMHA COVID-19 CWs. PTSD symptoms were reported as severe by 13% of the population. Depressive symptoms as severe for 7% and Anxiety symptoms as severe for 14%. Severe psychotic symptoms were experienced by 2% and severe suicidal thoughts by 1% of the population. The possibility of acting upon the results of the TMHA COVID-19 CWs allowed an early intervention through individual session beyond the cut-off level for PTSD in NSESSS. In fact, 280 individual support sessions were offered. Therefore, we considered our project a protective and support factor for healthcare workers’ mental well-being and we recommend implementing a mental health screening program in ward involved in COVID-19 patients’ care. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Working with Patience:An Insight into Dealing with Difficult EmotionsDavid VilanovaAs the most trusted professionals in the nation, nurses are expected to care for their patients with empathy and freedom from bias. The reality is that nurses are human, and some form of implicit bias is inevitable. In my own experience, this issue has reared its head on several occasions. My nursing background is prominently in cardiac and (...) intensive care. Seeing patients at their most vulnerable has become a regular part of my practice. Among some of the most challenging cases for me have been when I assume care of a patient withdrawing from alcohol. As an adult child with close alcoholic family members, many instances of abuse and pain stick with me today and these are brought to the surface when I care for patients with alcohol use disorder. In most cases, I easily find a healthy balance between remaining an understanding-and-empathetic provider and protecting my emotional and mental health as I navigate ethical and moral issues. However, with this patient population, walking that fine line is especially challenging. How do I navigate and manage intensely personal emotions and biases while providing the high-quality care I vowed to deliver regardless of my patient's life choices, addictions, and illnesses? How do I maintain an appropriate level of neutrality and clarity as this patient's behavior and attitude spark emotional triggers? In other words, how do I take care of someone I don't like?Mrs. H was a middle-aged Hispanic woman, barely coherent, but speaking clearly enough that I could understand her slurred speech. Immediate dread washed over me as I realized my assignment included a patient withdrawing from alcohol. The patient's affect, incoherence, and aggression were all too reminiscent of a traumatic past I still work to heal from. My coworkers couldn't understand her insults and obscenities and were therefore unphased except for noting her unruly and erratic behavior. On the other hand, I could understand much of what she was yelling at me and any other staff who bravely walked into her room. My immediate thoughts were that this woman clearly did not want our help. My every attempt to enter her room, speak with her, and provide care were met with an all too familiar rejection and denial that she even had a problem. Yet here she was in a hospital room, and I was her nurse. She verbalized denial of drinking too much when told that she was being treated for alcohol withdrawal. She stated this denial more to herself than to the health care providers in the room, and it was reminiscent of the denial I have seen in my loved ones. This was ironic, I always thought, as the need for such self-deception in and of itself points to the fact that something may be wrong and worth addressing.But denial or not, today, this patient—Mrs. H, was entrusted into my care. She refused treatments and medications, and this put me in a complex ethical predicament—treating a patient that I do not like for the personal issues she reminds me of, and the treatment of a patient against their refusal, as she was deemed incapable of making her own decisions. The latter of these two issues was easiest to put aside. Legally, this patient needed to be treated through her alcohol withdrawal. Once her mental status cleared up, she could sign out against medical advice or choose to remain until a safe discharge plan was in place. There was a protocol and legal guidelines for this situation. However, no guidelines [End Page 10] truly exist when it comes to the management of a patient that you simply do not like. The result can be a near-instantaneous dread each time you must answer that patient's bed alarm, call light, or most basic needs. A negative bias takes over, and it would be an understatement to say that this affects the quality of care. Patients in situations like this—with providers who judge them as I have been guilty of—can easily become subject to derogatory remarks, health inequities, and biased labeling... (shrink)

BackgroundResuscitation and treatment of critically ill newborn infants is associated with relatively high mortality, morbidity and cost. Guidelines relating to resuscitation have traditionally focused on the best interests of infants. There are, however, limited resources available in the neonatal intensive care unit, meaning that difficult decisions sometimes need to be made. This study explores the intuitions of lay people regarding resource allocation decisions in the NICU.MethodsThe study design was a cross-sectional quantitative survey, consisting of 20 hypothetical rationing scenarios. (...) There were 119 respondents who entered the questionnaire, and 109 who completed it. The respondents were adult US and Indian participants of the online crowdsourcing platform Mechanical Turk. Respondents were asked to decide which of two infants to treat in a situation of scarce resources. Demographic characteristics, personality traits and political views were recorded. Respondents were also asked to respond to a widely cited thought experiment involving rationing.ResultsThe majority of respondents, in all except one scenario, chose the utilitarian option of directing treatment to the infant with the higher chance of survival, higher life expectancy, less severe disability, and less expensive treatment. As discrepancy between outcomes decreased, however, there was a statistically significant increase in egalitarian responses and decrease in utilitarian responses in scenarios involving chance of survival, life expectancy, and cost of treatment. In the classic ‘lifeboat’ scenario, all but two respondents were utilitarian.ConclusionsThis survey suggests that in situations of scarcity and equal clinical need, non-health professionals support rationing of life-saving treatment based on probability of survival, duration of survival, cost of treatment or quality of life. However, where the difference in prognosis or cost is very small, non-health professionals preferred to give infants an equal chance of receiving treatment. (shrink)

The chronic worldwide lack of organs for transplantation and the continuing improvement of strategies for in situ organ preservation have led to renewed interest in elective non-therapeutic ventilation of potential organ donors. Two types of situation may be eligible for elective intensive care: patients definitely evolving towards brain death and patients suitable as controlled non-heart beating organ donors after life-supporting therapies have been assessed as futile and withdrawn. Assessment of the ethical acceptability and the risks of these strategies (...) is essential. We here offer such an ethical assessment using the four principles of medical ethics of Beauchamp and Childress applying them in their broadest sense so as to include patients and their families, their caregivers, other potential recipients of intensive care, and indeed society as a whole. The main ethical problems emerging are the definition of beneficence for the potential organ donor, the dilemma between the duty to respect a dying patient's autonomy and the duty not to harm him/her, and the possible psychological and social harm for families, caregivers other potential recipients of therapeutic intensive care, and society more generally. Caution is expressed about the ethical acceptability of elective non-therapeutic ventilation, along with some proposals for precautionary measures to be taken if it is to be implemented. (shrink)

In this article, we report findings from a qualitative study that explored how the relatives of intensive care unit patients experienced the nurses’ role and relationship with them in the end-of-life decision-making processes. In all, 27 relatives of 21 deceased patients were interviewed about their experiences in this challenging ethical issue. The findings reveal that despite bedside experiences of care, compassion and comfort, the nurses were perceived as vague and evasive in their communication, and the relatives missed (...) a long-term perspective in the dialogue. Few experienced that nurses participated in meetings with doctors and relatives. The ethical consequences imply increased loneliness and uncertainty, and the experience that the relatives themselves have the responsibility of obtaining information and understanding their role in the decision-making process. The relatives therefore felt that the nurses could have been more involved in the process. (shrink)

Background:Moral distress is a common problem among professionals working in the field of healthcare. Moral distress is the distress experienced by a professional when he or she cannot fulfill the correct action due to several obstacles, although he or she is aware of what it is. The level of moral distress experienced by nurses working in intensive care units varies from one country/culture/institution to another. However, in Turkey, there is neither a measurement tool used to assess moral distress (...) suffered by nurses nor a study conducted on the issue.Aim/objective:The study aims to (a) validate the Turkish version of the Moral Distress Scale–Revised to be used in intensive care units and to examine the validity and reliability of the Turkish version of the scale, and (b) explore Turkish intensive care nurses’ moral distress level.Method:The sample of this methodological, descriptive, and cross-sectional design study comprises 200 nurses working in the intensive care units of internal medicine and surgical departments of four hospitals in three cities in Turkey. The data were collected with the Socio-Demographic Characteristics Form and The Turkish Version of Moral Distress Scale–Revised.Ethical considerations:The study proposal was approved by the ethics committee of the Faculty of Medicine, Cumhuriyet University. All participating nurses provided informed consent and were assured of data confidentiality.Results:In parallel with the original scale, Turkish version of Moral Distress Scale–Revised consists of 21 items, and shows a one-factor structure. It was determined that the moral distress total and item mean scores of the nurses participating in the study were 70.81 ± 48.23 and 3.36 ± 4.50, respectively.Conclusion:Turkish version of Moral Distress Scale–Revised can be used as a reliable and valid measurement tool for the evaluation of moral distress experienced by nurses working in intensive care units in Turkey. In line with our findings, it can be said that nurses suffered low level of moral distress. However, factors which caused the nurses in our study to experience higher levels of moral distress are inadequate communication within the team, working with professionals they considered as incompetent, and futile care. (shrink)

This study was conducted to gain opinions about euthanasia from nurses who work in intensive care units. The research was planned as a descriptive study and conducted with 186 nurses who worked in intensive care units in a university hospital, a public hospital, and a private not-for-profit hospital in Adana, Turkey, and who agreed to complete a questionnaire. Euthanasia is not legal in Turkey. One third (33.9%) of the nurses supported the legalization of euthanasia, whereas 39.8% (...) did not. In some specific circumstances, 44.1% of the nurses thought that euthanasia was being practiced in our country. The most significant finding was that these Turkish intensive care unit nurses did not overwhelmingly support the legalization of euthanasia. Those who did support it were inclined to agree with passive rather than active euthanasia (P = 0.011). (shrink)

Abstract:Discussions of conscientious objection (CO) in healthcare often concentrate on objections to interventions that relate to reproduction, such as termination of pregnancy or contraception. Nevertheless, questions of conscience can arise in other areas of medicine. For example, the intensive care unit is a locus of ethically complex and contested decisions. Ethical debate about CO usually concentrates on the issue of whether physicians should be permitted to object to particular courses of treatment; whether CO should be accommodated. In this (...) article, I focus on the question of how clinicians ought to act: should they provide or support a course of action that is contrary to their deeply held moral beliefs? I discuss two secular examples of potential CO in intensive care, and propose that clinicians should adopt a norm of conscientious non-objection (CNO). In the face of divergent values and practice, physicians should set aside their personal moral beliefs and not object to treatment that is legally and professionally accepted and provided by their peers. Although there may be reason to permit conscientious objections in healthcare, conscientious non-objection should be encouraged, taught, and supported. (shrink)

Caring for a child in a pediatric intensive care unit is emotionally and physically challenging and often leads to conflict. Skilled mediators may not always be available to aid in conflict resolution. Careproviders at all levels of training are responsible for managing difficult conversations with families and can often prevent escalation of conflict. Bioethics mediators have acknowledged the important contribution of mediation training in improving clinicians’ skills in conflict management. Familiarizing careproviders with basic mediation techniques is an important (...) step towards preventing escalation of conflict. While training in effective communication is crucial, a sense of fairness and justice that may only come with the introduction of a skilled, neutral third party is equally important. For intense conflict, we advocate for early recognition, comfort, and preparedness through training of clinicians in de-escalation and optimal communication, along with the use of more formally trained third-party mediators, as required. (shrink)

There have been few empirical studies into what non-medical factors influence physicians and nurses when deciding about admission and discharge of ICU patients. Information about the attitudes of healthcare professionals about this process can be used to improve decision-making about resource allocation in intensive care. To provide insight into ethical problems that influence the ICU admission and discharge process, we aimed to identify and explore ethical dilemmas healthcare professionals are faced with.

Background Moral distress has negative effects on physical and mental health. However, there is little information about nurses’ coping strategies reducing moral distress. Aim The purpose of this study was to investigate the coping strategies of intensive care unit nurses reducing moral distress in Iran. Study design This is a qualitative study with a content analysis approach. Participants and research context The research sample consisted of nurses working in intensive care units of teaching hospitals affiliated to (...) Tehran University of Medical Sciences. Samples were selected among eligible nurses by purposive sampling. Data were obtained through 17 in-depth, individual, and semi-structured interviews with 17 nurses. Graneheim and Lundman’s (2004) 6-step content analysis method was used to analyze the data. Data management was also performed by MAXQDA software version 20. The COREQ checklist was used to report the study. Ethical considerations This project was approved by the Ethics Committee of Tehran University of Medical Sciences. All ethical guidelines in research were followed. Finding The data analysis resulted in the formation of two main categories of desirable coping strategies (with two subcategories of compensation and rejuvenation) and less desirable coping strategies (with three subclasses of indifference over time, escape and concealment). Discussion The intensive care unit nurses in dealing with ethical problems first try to solve the problem through discussion, but when they fail to resolve it peacefully, they resort to several coping strategies. Factors, such as increasing experience, lack of support from hospital managers and officials, poor communication between colleagues, the need to maintain hierarchy, fear of reprimand, and a sense of powerlessness, changed the nurses’ preferred strategies. It is important for managers to provide a blame/punishment-free atmosphere for expression of ethical experiences; a supportive atmosphere in which staff can engage in ethical discussions without fear of punishment. They should also provide opportunities for rest, rejuvenation, and adequate training for their employees. (shrink)

Background: Less sedated and more awake patients in the intensive care unit may cause ethical challenges. Research objectives: The purpose of this study is to describe ethical challenges registered nurses experience when patients refuse care and treatment. Research design: Narrative individual open interviews were conducted, and data were analysed using a phenomenological hermeneutic method developed for researching life experiences. Participants and research context: Three intensive care registered nurses from an intensive care unit at (...) a university hospital in Norway were included. Ethical considerations: Norwegian Social Science Data Services approved the study. Permission was obtained from the intensive care unit leader. The participants’ informed and voluntary consent was obtained in writing. Findings: Registered nurses experienced ethical challenges in the balance between situations of deciding on behalf of the patient, persuading the patient and letting the patient decide. Ethical challenges were related to patients being harmful to themselves, not keeping up personal hygiene and care or hindering critical treatment. Discussion: It is made apparent how professional ethics may be threatened by more pragmatic arguments. In recent years, registered nurses are faced with increasing ethical challenges to do no harm and maintain dignity. Conclusion: Ethically challenging situations are emerging, due to new targets including conscious and aware critical care patients, leaving an altered responsibility on the registered nurses. Reflection is required to adjust the course when personal and professional ideals no longer are in harmony with the reality in the clinical practice. RNs must maintain a strong integrity as authentic human beings to provide holistic nursing care. (shrink)

Background: Maintaining patient’s dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units. Objectives: The aim of this study was to uncover the cultural factors that impeded maintaining patients’ dignity in the cardiac surgery intensive care unit. Research Design: The study was conducted using a critical ethnographic method proposed by Carspecken. Participants and research context: Participants included all physicians, nurses and staffs working in the (...) study setting (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace. Ethical Consideration: Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained. Findings: The findings of the study fell into the following main themes: “Presence: the guarantee for giving enough attention to patients’ self-esteem”, “Instrumental and objectified attitudes”, “Adherence to the human equality principle: value-action gap”, “Paternalistic conduct”, “Improper language”, and “Non-interactive communication”. The final assertion was “Reductionism as a major barrier to the maintaining of patient’s dignity”. Discussion: The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches. Conclusion: Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships. (shrink)