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.

The Calgary Conjoint Nursing Program. Part II: Successful political action.

When three calgary institutions decided to develop a collaborative nursing program to prepare for the transition to baccalaureate nursing education by the year 2000, the planners found that they had to overcome a broad range of political and institutional hurdles. Faculty from Mount Royal College, Foothills Hospital School of Nursing and the University of Calgary spent six years developing the curriculum and planning for the implementation of the Calgary Conjoint Nursing Program (CCNP). (See The Calgary Conjoint Nursing Program, Part I: Spirit of Collaboration, in the March 1999 issue of this journal.)

The Calgary Conjoint Nursing Program. Part I: Spirit of collaboration.

On January 26, 1993, a small but significant gathering in Calgary celebrated the government's approval of the Calgary Conjoint Nursing Program. In attendance were faculty and staff of the nursing education programs of the Foothills Hospital School of Nursing, Mount Royal College and the University of Calgary, as well as senior administrators from each of those sites, practising nurses and a member of Alberta's Legislative Assembly. The group was celebrating the culmination of six years of working together toward the realization of a co-operative, collaborative baccalaureate nursing education program.

Is practical nursing experience necessary in administration, education, and research?

Because nursing is a practice discipline involving a relationship between nurse and client based on moral commitments of nurse to client, it is critically important that nurse administrators, educators, and researchers have experienced that relationship in practice. Nurse administrators need that basis to found a vision of nursing required to lead and guide. Nurse educators need to have experienced nursing practice to engage nursing students in praxis, that act of reflection and action. Nurse researchers need to have practiced nursing to identify critical areas of focus in nursing practice and to give meaning to the interpretation of findings. The author urges greater convergence and clarity in identifying the nonnegotiables of nursing's art and science, including the importance of nursing practice as foundational to nursing work.

Public attitudes towards end-of-life treatment decisions: implications for nurse clinicians and nursing administrators.

As medical technology becomes more sophisticated, end-of-life treatment decisions become more complex for patients and for the professionals who care for them. The authors surveyed 448 members of the general public to determine their attitudes regarding end-of-life treatment decisions and attitudes towards the provision of advance end-of-life directives. A slight minority of respondents indicated they would leave major decisions to their physicians. An overwhelming majority believe that living wills are important. Most respondents indicated they would not wish their lives to be prolonged if elderly and ill or if their minds failed. A majority of respondents also were in favour of donating their organs after death. The article reports the socio demographic variables which significantly influenced these responses and suggests the implications of these results for nurse clinicians and for nursing administrators. Enhancing clients' abilities to communicate their wishes and being sensitive to social-cultural differences in perspectives about these issues, are key implications for nurse clinicians. Ensuring sound policies and guidelines are developed and that adequate education is provided in ethical and legal dimensions surrounding end-of-life treatment directives, as well as multi-cultural orientation, are responsibilities for nursing administrators.

Hospital ethics committees: problems in evaluation.

Hospital ethics committees continue to proliferate, despite the fact that their impact upon practice has not been rigorously evaluated. This paper investigates the reasons why the often recommended evaluation has not yet occurred. One reason cited is that three different roles - education, policy formulation, and case review - need to be assessed. The principal reason why the most novel of the roles, case review, has not been evaluated is because of unresolved dispute over the goals of review.

Ethics committees in Canadian hospitals: report of the 1990 pilot study.

The second phase of a Canada-wide study of ethics committees in English-language hospitals in Canada involved site visits to five selected hospitals to assess the effectiveness of the ethics committee. In this article the findings of this pilot study are reported, including the perspectives of physicians, nurses and hospital administrators on the ethics committee of the various hospitals. The results of the study, albeit limited by being a pilot study, raise a series of questions for hospital administrators, medical administrators and nursing administrators.

Ethics committees in Canadian hospitals: report of the 1989 survey.

A survey of English-language hospitals with more than 300 beds in Canada was conducted in 1989 to assess institutional ethics committees. A dramatic increase was found in the growth of such committees, compared with a similar survey taken in 1984. The growth and the activities of institutional ethics committees are discussed, noting the need for more attention for research on their effectiveness.

Hospital administrators as professionals: a study of occupational role identity.

This study set out to examine how hospital administrators see themselves in relation to their occupational role, that is, do they see themselves primarily as professionals, as organizational men and women, or as some combination of both. The determinants of their perceptions of occupational role identity were also examined. Canadian hospital CEOs numbering 361 were surveyed with a 72 percent response rate showing wide variation in education and length of work experience. Findings indicate these CEOs manifest a combination of professional and organizational role identities with no apparent conflict between these identities and no systematic differences in role identity by type of education or by length of work experience. The structure of this integrated model of professionalism and its potential impact on the leadership role of the CEO is examined in this article.

Women executives in Canadian hospitals.

Despite a high percentage of female graduates from health services administration (HSA) programs since the late 1970s, there is little evidence that the increase has translated into greater employment for women in the top positions in Canadian hospitals. Results of an analysis of data from a 1987 study of chief executive officers (CEOs) in Canadian hospitals are reported relative to difference by gender. These data show that women CEOs are better educated, more experienced, older and likely to be more mobile than their male counterparts. Several suggestions to increase the acceptance of women into top health administrative positions in hospitals are offered.

Studies of health executives in Canada: a review and comparison.

There are a limited number of national studies of health executives in Canada and the few that do exist are not well known to the average executive. In this article, these studies are reviewed, and the demographic findings of three more recent studies are compared in respect to hospital CEOs. Three potential trends are noted: an upward shift in level of education of CEOs, with a steady but not increasing representation of M.H.S./M.H.S.A. graduates; a decreasing length of tenure in hospital CEO positions with evidence of recent turnover in many CEO positions; and a continuing male dominance in hospital CEO positions. It is suggested that the implications of these trends should be considered as they apply to the education of health executives and as they affect the effectiveness of healthcare.

Teaching ethics: preparing health services managers for ethical decision making.

This article offers general comments on the necessity for ethics education and proposes a model for ethics education for health services managers. The model incorporates the premises on which ethics education should be based and the suggested content, methods, and approaches at various levels for such a program.