Listening to nurses' moral voices: building a quality health care environment.

In this paper we describe a research project in nursing ethics aimed at exploring the meaning of ethics for nurses providing direct care with clients. This was a practice-based project in which participants who were staff nurses, nurses in advanced practice, and students in nursing were asked to tell us (or describe to us) how they thought about ethics in their practice, and what ethical practice meant to them. We then undertook to analyze, describe and understand the enactment of ethical practice, the opportunities for and barriers to such enactment, as well as the resources nurses need for ethical practice. We drew out implications of these findings for nursing leaders. We identified practice realities that create a climate for ethical or moral distress, and the way in which nurses attempt to maintain their moral agency. Practice realities included nurses' ethical concerns about policies guiding care; the financial, human and temporal resources available for care; and the power and conflicting loyalties nurses encounter inproviding good care. Maintaining moral agency involved use of a variety of ethical resources and the identification of resources needed to provide good care, as well as the processes used to enact moral agency. Nurse leaders are also moral agents. Important implications of these findings for nursing leaders are that they need moral courage to be self-reflective, to name their own moral distress, and to act so that their nursing staff are able to be moral agents. Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent and ethical practice.

Patient and family adjustment to kidney transplantation with and without an interim period of dialysis.

This exploratory study was designed to examine the process of patient and family adjustment to kidney transplantation and to compare differences between those who had and those who did not have dialysis pretransplant. To capitalize on benefits of longitudinal and cross-sectional designs, a mixed-method approach described by Aaronson and Kingry (1988) was used. Participants were recruited from two major transplant centers in Western Canada. Twenty patients with ESRD and their partners were studied longitudinally at three points: during the period before the kidney transplant assessment phase and then at 3 and 6 months posttransplant. Forty-seven ESRD patients and their partners comprised the cross-sectional sample. Participants comprising the cross-sectional sample provided responses from at least one of the three time points. Patients and/or their partners completed a series of questionnaires focusing on family functioning (Family Inventory of Life Events and Change [FILE], Feetham Family Functioning Survey [FFFS]); support and resources (Family Inventory of Resources for Management [FIRM]); as well as uncertainty (Uncertainty Stress Scale [USS]); sickness impact (Sickness Impact Profile [SIP]); and sense of coherence (Sense of Coherence Scale [SOC]). The findings indicated that patients and their partners were under considerable stress as they underwent kidney transplantation. Illness and family care strains as well as financial strains were significant. The participants expressed low to moderate uncertainty that decreased over time from the pretransplant to the posttransplant period. Patients on dialysis prior to transplant were more physically and psychologically affected than patients pre-empted to transplant. Those who were pre-empted to transplant reported minimal impact pretransplant but considerable improvement in their psychological and physical state posttransplant. In conclusion, transplantation without prior dialysis resulted in less physical and psychological impact for patients and their spouses. These findings point to a need for interdisciplinary education and support programs at both the pretransplant and posttransplant phase to help patients and their partners adjust to living with a kidney transplant. Given the beneficial effects of pre-emptive transplantation, emphasis must be placed on increasing the organ donor pool so that more pre-emptive transplants can be conducted.

When is it right to die?

Advances in technology and the increased awareness and activism of health care consumers have brought a heightened focus to the ethical questions associated with end-of-life decision-making in health care. This attention is manifested in increased discussion, both in the literature and informally, of end-of-life issues; in increased numbers of advanced directives; and, recently in Canada, in the formation of the Senate Committee on Euthanasia and Assisted Suicide whose charge was to develop policy on these issues. Nurses have valuable perspectives to add to this discourse.

Family decision making about living related kidney donation.

Little information is available on how families make decisions about living related kidney donation. The purpose of this study, therefore, was to explore the family decision making process in identifying and selecting a living related kidney donor, to identify factors that assist or inhibit the decision making, and to explore issues and concerns raised by families about the experience. The qualitative method of grounded theory was used. Ten recipients, their living related donors, and their family members were interviewed individually and as a group prior to and after the transplant. Four decisions were required of most families. Three decision-making patterns--straightforward, moderately straightforward, and complex were identified as well as the factors that influenced the process.

Constraints on the moral agency of nurses.

Awareness of nurses' ethical concerns has increased greatly over the last few years. In response to this awareness, the Canadian Nurses Association revised the Code of Ethics to provide direction for the implementation of ethical standards for nursing. Yet, a growing body of literature suggests that situational constraints make it difficult for nurses to uphold these standards. Overcoming these constraints will take concerted efforts in nursing education, administration, practice and research.