Moral distress in nurses in developing economies: an integrative literature review.

Background: Moral distress has been extensively studied in developed economies; however, not much in terms of studies has been carried out in developing economies. Objective: To review the literature reporting the experience of moral distress in nurses in health care settings in developing economies. Design: An integrative literataure review was used. Method: Cumulative Index of Nursing and Allied Health Literature, Medical Literature Analysis and Retrieval System Online Cochrane and Psych INFO were searched to retrieve titles and abstracts of papers on the experience of moral distress in nurses in developing economies. Results: Sixteen articles reporting the experience of moral distress in nurses in developing economies published between 1984 and March 2019 were used for the review. Analysis of the findings revealed seven themes, nurses' experience of moral distress, inadequate material and human resources, end-of-life challenges, cultural and religious beliefs as a source of moral distress, perceived inactions of medical and nursing staff, impact of moral distress on nurses in developing economies and coping strategies. Conclusion: There is paucity of empirical studies on moral distress in nurses in developing economies. More qualitative studies are needed in various cultural settings to enhance its understanding in nurses working in developing economies.

Moral distress experienced by neonatal intensive and paediatric care nurses in Northern Ghana: a qualitative study.

Background: Moral distress has been studied widely in nursing but not in developing economies. Aim: To investigate how moral distress is experienced by nurses working in neonatal intensive care and paediatric wards in Northern Ghana and to determine support measures offered by nurse managers. Method: Qualitative descriptive method. Forty nurses and fourteen nurse managers working with children in four hospitals in Northern Ghana were interviewed. Thematic data analysis was carried out. Results: Six themes were identified: nurses experience morally distressing situations due to a variety of causes; the impact of morally distressing situations on nurses; coping mechanisms of nurses who experienced morally distressing situations; recommendations made by the nurses to reduce the incidence of moral distress; inadequate support measures available to nurse managers and nurse managers experience moral distress too. Conclusion: The causes of moral distress in developed and developing economies are similar. The frequency and intensity of moral distress is high in Northern Ghana. Consistent with other studies conducted in Africa, nurses and nurse managers relied on their religious faith as a form of resilience. No support measures are available to nurse managers to support nurses who experience moral distress.

Covid-19, ethical nursing management and codes of conduct: An analysis.

The conduct of nurse managers, and health service managers more widely, has been subject to scrutiny and critique because of high-profile organisational failures in healthcare. This raises concerns about the practice of nursing management and the use of codes of professional and managerial conduct. Some responses to such failures seem to assume that codes of conduct will ensure or at least increase the likelihood that ethical management will be practised. Codes of conduct are general principles and rules of normative standards, including ethical standards, and guides for action of agents in particular roles. Nurse managers seem to stride two roles. Contra some accounts of the roles of a professional (nurse) and that of a manager, it is claimed that there is no intrinsic incompatibility of the roles though there is always the possibility that it could become so and likewise for codes of conduct. Codes of conduct can be used to support nurse managers in making practical decisions via an 'outside in' approach with an emphasis on the use of principles and an 'inside out' approach with an emphasis on the agent's character. It is claimed that both approaches are necessary, especially as guides to ethical action. However, neither is sufficient for action because judgement and choice will always be required (principles always underdetermine action) as will a conducive environment that positively influences good judgement by being supportive of the basic principles and values of healthcare institutions. The response to the Covid-19 pandemic has created a unique set of circumstances in which the practical judgement, including ethical judgement, of nurse managers at all levels is being tested. However, the pandemic could be a turning point because staff and institutions (temporarily) freed from managerialism have demonstrated excellent practice supportive of ethical and other practical decision making. Organisations need to learn from this post pandemic.

Human rights education in patient care: A literature review and critical discussion.

The identification of human rights issues has become more prominent in statements from national and international nursing organisations such as the American Nurses Association and the United Kingdom's Royal College of Nursing with the International Council of Nursing asserting that human rights are fundamental to and inherent in nursing and that nurses have an obligation to promote people's health rights at all times in all places.However, concern has been expressed about this development. Human rights may be seen as the imposition of legal considerations for nurses and other healthcare workers to bear in mind, as yet more responsibilities with the consequent fear of litigation. Although a more hopeful scenario is that consideration of human rights is something that is supportive of good practice.If this more hopeful scenario is to be realised, the role of education will be crucial. As with human rights generally, human rights education is a global phenomenon, a practice-orientated expression of the Universal Declaration of Human Rights, and the goal of human rights education is to build a culture of respect and action for human rights for all.However, the nature of human rights has long been contested. A 'mapping exercise' of the academic literature on human rights identified 'four schools' or 'ideal types' that have shaped thinking about human rights. This sets out the conceptual context in which human rights problems are defined and solutions are proposed, which is particularly important for human rights education. However, it also complicates the picture. The different approaches taken by the four 'types' would likely lead to different outcomes in terms of human rights education.It is timely to discuss the nature of human rights education and examine its potential for impact on patient care. This will involve identifying the challenges and potential benefits of this approach and analysing the implications for professional practice.

Morality, normativity and measuring moral distress.

It is known that people have been getting distressed for a long-time and healthcare workers, like the military, seem to fit criteria for being at particular risk. Fairly recently a term of art, moral distress, has been added to types of distress at work, though not restricted to work, they can suffer. There are recognized scales that measure psychological distress such as the General Health Questionnaire and the Kessler scales but moral distress it is claimed is different warranting its own scale. This seems to be because of both the intensity and nature of moral problems encountered at work that is so powerful and so destructive of moral agency and integrity. This paper will focus on how, if at all, moral distress is different by examining the idea of moral normativity. Moral normativity is understood as roughly the sort of thing that all rational persons would endorse regardless of his interests, having an "automatic reason giving force" and is likely to also require an overriding force. Specifically, it will examine how this force of moral claims seems to be needed for moral distress to be so destructive of healthcare professional's moral agency and integrity. This is related to the idea of warrantedness of the reaction of distress. Even if morality had such a strong normativity, one can still ask is distress the correct or warranted reaction? It seems plausible that if distress is a correct response for it to be both moral and warranted it needs a strong account of moral normativity. The idea of a distinct form of distress as moral distress may be true in theory but is too contested both ontologically and epistemologically for a useful practice of measurement at present.

Understanding the relevance of human rights in healthcare and nursing practice.

While the NHS aims to respect the human rights of every individual, it also has a wider social duty to promote equality in the services it provides. This means that the rights of individual patients are not absolute, because the aim of the NHS is to improve the overall health and well-being of the nation. For example, certain treatments may be withheld from individuals because of the excessive cost to the NHS, or concerns about its clinical effectiveness. This article explains the origins of human rights and their function, and examines the relationship between nursing care and human rights.

Understanding and applying personality types in healthcare communication.

Understanding personality types can assist nurses in enhancing their understanding of themselves and their colleagues, which in turn can support effective communication. This article outlines the principles of the Myers-Briggs Type Indicator (MBTI) - a personality inventory that aims to improve the understanding of psychological types - and details the characteristics of the MBTI's 16 different personality types. The article explores how these 16 personality types can influence communication within healthcare teams and between healthcare professionals. It also discusses how these personality types affect styles of nurse leadership and how an understanding of personality types can improve nurses' communication with patients.

To explore the experience of research nurses who obtain consent from adults in emergency settings to participate in clinical trials, either prospectively or post enrolment.

AIM: To explore the understanding and experiences of research nurses who obtain informed consent from adult patients participating in emergency care research. DESIGN: Qualitative phenomenographic descriptive study. METHODS: Ten research nurses from six hospitals in England were recruited. Data were collected using semi-structured face-to-face and telephone interviews between January 2019 and March 2019. Interviews were transcribed verbatim and analysed thematically, informed by phenomenography. COREQ was followed. RESULTS: Three main themes were identified: (a) emergency research is different, (b) protecting the patient, and (c) experience and confidence with recruitment. It was found that obtaining patient consent in emergency care research was challenging and timing of the process was crucial. Nurses with more experience of emergency care were more confident in approaching patients and their families. There was variability in out-of-hours recruitment which was a consequence of the range of informed consent processes used and the different levels of engagement of clinical teams. CONCLUSION: There is a variety of organisational cultures, processes and procedures which affect the way consent is obtained in emergency care research. A team approach was evident in the hospitals where consent rates were high and was more successful than those reliant solely on the presence of a research nurse. Organisations were able to recruit successfully to emergency care research studies irrespective of size and configuration. Further investigation of their models of working and strategies for engagement is needed. Experienced research nurses made a positive difference to recruitment and were more likely to approach patients to obtain consent. RELEVANCE TO CLINICAL PRACTICE: The understanding and experiences of recruitment to clinical trials in emergency care research by research nurses can help identify barriers to recruitment. This study provides useful insights for healthcare practitioners, clinical trials coordinators and sponsors about how best to develop protocols and policies to increase recruitment to emergency care research.

What are research nurses' experiences of obtaining consent from or for patients participating in emergency care research? A qualitative review.

INTRODUCTION: If studies are to be valid, recruitment of representative samples is essential. In 2012, 28% of UK emergency departments met the 80% standard for recruitment to trials set by the National Institute for Health Research. Research nurses play a vital role in the conduct of high-quality research, and it has been argued that dedicated research nurses are needed if clinical trials are to recruit successfully to target. REVIEW QUESTION: What are research nurses' experiences of obtaining consent from or for patients participating in emergency care research? A qualitative evidence review. METHODS: A qualitative integrative literature review with a narrative synthesis of the evidence. PRISMA guidelines for reporting systematic qualitative reviews (Appendix S1) were followed. A search of five electronic databases was performed in December 2018 along with a hand search which yielded 125 citations: 10 papers and one PhD thesis met the review eligibility criteria. Methodological quality of the selected studies was evaluated, and data were extracted and synthesised. RESULTS: Three themes were identified: Access, Organisation and Timing. Research nurses encountered both general and specific barriers when seeking to obtain consent for participation in research. In particular, it was found there was lack of experience among staff of working in emergency research and with securing deferred consent. The distinction between nurse researchers with a clinical role and those dedicated to solely to research only is often not clear and warrants further investigation. CONCLUSION: Nurse researchers with and without a clinical role can make a positive difference in recruitment to trials in emergency care. The involvement of dedicated research nurses in the consent process can increase recruitment to emergency care research. Experience of recruiting to clinical trials in nonemergency settings does not seem to help when recruiting for trials in emergency care. RELEVANCE TO CLINICAL PRACTICE: There is a need for greater understanding of the experiences of dedicated research nurses in emergency care settings and in particular with regard to deferred consent.

A moral profession: Nurse educators' selected narratives of care and compassion.

BACKGROUND:: Lack of compassion is claimed to result in poor and sometimes harmful nursing care. Developing strategies to encourage compassionate caring behaviours are important because there is evidence to suggest a connection between having a moral orientation such as compassion and resulting caring behaviour in practice. OBJECTIVE:: This study aimed to articulate a clearer understanding of compassionate caring via nurse educators' selection and use of published texts and film. METHODOLOGY:: This study employed discourse analysis. PARTICIPANTS AND RESEARCH CONTEXT:: A total of 41 nurse educators working in universities in the United Kingdom (n = 3), Ireland (n = 1) and Canada (n = 1) completed questionnaires on the narratives that shaped their understanding of care and compassion. FINDINGS:: The desire to understand others and how to care compassionately characterised educators' choices. Most narratives were examples of kindness and compassion. A total of 17 emphasised the importance of connecting with others as a central component of compassionate caring, 10 identified the burden of caring, 24 identified themes of abandonment and of failure to see the suffering person and 15 narratives showed a discourse of only showing compassion to those 'deserving' often understood as the suffering person doing enough to help themselves. DISCUSSION:: These findings are mostly consistent with work in moral philosophy emphasising the particular or context and perception or vision as well as the necessity of emotions. The narratives themselves are used by nurse educators to help explicate examples of caring and compassion (or its lack). CONCLUSION:: To feel cared about people need to feel 'visible' as though they matter. Nurses need to be alert to problems that may arise if their 'moral vision' is influenced by ideas of desert and how much the patient is doing to help himself or herself.

To explore the prevalence and outcomes of advance care planning for patients with left ventricular assist devices: A review.

AIMS AND OBJECTIVES: To explore the prevalence and outcomes of advance care planning for patients with left ventricular assist devices: a review. BACKGROUND: End-stage heart failure is associated with significant symptom burden at rest. Left ventricular assist devices are not curative; nevertheless, they alleviate symptoms and prolong survival. Evidence suggests that most patients with left ventricular assist devices and their families do not have open discussions regarding end-of-life wishes until catastrophic complications arise. Therefore, it is important to understand reasons for this, so healthcare professionals such as nurses can facilitate the process. DESIGN: A mixed-studies integrative review with a narrative synthesis of the evidence. PRISMA guidelines were followed for reporting systematic qualitative reviews. METHOD: A search of four electronic data in January 2018 and a hand search yielded 139 citations; seven studies met the review eligibility criteria. Methodological quality of the selected studies was evaluated, and data were extracted and compiled. RESULTS: Three themes were identified: prevalence and feasibility of advanced care planning, advance care planning developed for patients with device support, patients' and caregivers' perceptions of advanced care planning discussions. Advanced care planning is underused routinely implemented in left ventricular device centres. Pre-implantation advanced care planning is feasible and results in the highest rate of documented advance decisions which are useful for both patients and their loved ones in cases of complications. CONCLUSION: Strong evidence that left ventricular assist-specific advanced care planning is recommended for all left ventricular assist device patients to enable their treatment preferences in case of incurable complications. Palliative care services should collaborate with nurses in designing and facilitating advanced care planning for delisted transplant patients. Patients with left ventricular devices awaiting heart transplant and those waiting for myocardium healing are underrepresented in the current studies. Research on the optimal timing of advanced care planning in these groups of patients is indicated. RELEVANCE FOR CLINICAL PRACTICE: There is a need for improved approaches to advanced care planning for and with people with left ventricular devices.

A research-based mantra for compassionate caring.

BACKGROUND: The United Kingdom introduced the Six C's strategy to help address deficits in approaching nursing care in a compassionate and caring manner. OBJECTIVE: To identify the book, article, poem, film or play that most influenced nurse educators' understanding of care and compassion and to articulate a clearer understanding of compassionate caring. DESIGN: A qualitative study applying discourse analysis to respondents' questionnaires and their nominated narrative. SETTINGS AND PARTICIPANTS: 41 nurse educators working in 5 universities in the UK (n=3), Republic of Ireland and Canada participated. 39 items (10 books, 2 journal articles, 10 poems, 15 films and 2 plays) were nominated. FINDINGS: The desire to understand others and how to care compassionately characterised choices. Three main themes emerged. Abandonment of, and failure to see, the suffering person was evident in 25 narratives. Connecting with others was shown in 25 narratives as being able to truly seeing the other person. Comforting others was supported by 37 narratives with examples of kindness and compassion. CONCLUSION: Published narratives are valuable in developing compassionate responses. An annotated list is provided with suggestions for educational uses to help develop compassionate caring in student nurses. Compassionate, caring nurses recognise that patients need them to: "See who I am; Be present with me; Do not abandon me."

An adaptable instrument and method for exploring care and compassion.

Background Narratives, particularly when visual and auditory elements are added to words, reveal more about cultures and behaviours, including those present in professional and service settings. Discourse analysis (DA) enables researchers to explicate meanings and understandings linking culture and behaviour. Aim To explain the development of a DA instrument and method for a research study of caring and compassion as expressed in different media. Discussion The DA instrument assisted in systematic and multi-modal data analysis by several researchers from different countries and backgrounds. DA appears well-suited to revealing the complexities of caring and compassion by healthcare and social care educators, capturing 'objectivist' and 'subjectivist' accounts. While allowing differences, it also helped to achieve some commonality. Conclusion Together, the instrument and method could be used in educating nurses about care and compassion. Implications for practice The DA instrument and method can be adapted by other nurse researchers to examine complex human issues.

The emotion of compassion and the likelihood of its expression in nursing practice.

Philosophical and empirical work on the nature of the emotions is extensive, and there are many theories of emotions. However, all agree that emotions are not knee jerk reactions to stimuli and are open to rational assessment or warrant. This paper's focus is on the condition or conditions for compassion as an emotion and the likelihood that it or they can be met in nursing practice. Thus, it is attempting to keep, as far as possible, compassion as an emotion separate from both moral norms and professional norms. This is because empirical or causal conditions that can make experiencing and acting out of compassion difficult seem especially relevant in nursing practice. I consider how theories of emotion in general and of compassion in particular are somewhat contested, but all recent accounts agree that emotions are not totally immune to reason. Then, using accounts of constitutive conditions of the emotion of compassion, I will show how they are often likely to be quite fragile or unstable in practice and particularly so within much nursing practice. In addition, some of the conditions for compassion will be shown to be problematic for nursing practice. It is difficult to keep ideas of compassion separate from morality, and this connection is noticeable in the claims made of compassion for nursing and so I will briefly highlight one such connection that of the need for normative theory to give an account of the value that emotions such as compassion presume and that compassionate motivation is separate from moral motivation and may conflict with it. The fragility or instability of the emotion of compassion in practice has implications for both what can be expected and what should be expected of compassion; at least if what is wanted is a realist rather than idealist account of "should."

Pressure-ulcer management and prevention in acute and primary care.

This article describes a study to ascertain what it is like to follow the processes in practice for prevention and management of pressure ulcers as one aspect of care among others. The participants in this study were bands 5 and 6 staff nurses and healthcare assistants (HCAs) (n=72) recruited from two acute and two primary NHS trusts. Data were gathered from open-ended questions via an online survey (n=61) and interviews (n=11). The interviews were transcribed and all the data were analysed by thematic analysis. The findings show that participants believe there has been a high-profile imposition of guidelines and policies by management during at least the past 18 months, resulting in perceived good outcomes in the form of fewer pressure ulcers generally and less fragmentation of care, particularly within primary care. However, a number of perceived obstacles to the implementation of recommended interventions remain, notably lack of time and lack of knowledge.

Virtue ethics and nursing: on what grounds?

Within the nursing ethics literature, there has for some time now been a focus on the role and importance of character for nursing. An overarching rationale for this is the need to examine the sort of person one must be if one is to nurse well or be a good nurse. How one should be to live well or live a/the good life and to nurse well or be a good nurse seems to necessitate a focus on an agent's character as well as actions because character is (for the most part) expressed in action (e.g. see Laird). This paper will give an overview of the reasons for the role and importance of character in nursing practice and explain its relation to nursing's frequent use of virtue ethics in order to recommend caution. While the paper agrees that the role of character is important in nursing caution is needed in both how much moral and thus normative, emphasis is being placed on the psychology of character and on the drift to virtue ethics. The psychological which may be explanatory needs to be linked with the normative, and a justification for the normative is needed. A justification as virtue ethics is contested, and nursing practice does not need to take on this explanatory and justificatory burden. A tentative proposal raised but not discussed in depth in this paper is that when an ultimate explanation or explanatory ground is needed, nursing practice leads quite naturally to a form of consequentialism as well as a realist metaethic. On this account, there are two levels of moral thinking, and nursing practice entails the virtues at one level and leads quite naturally to moral thinking at another more critical level of the criterion of what makes something right and good independently of character.

Contemporary nursing wisdom in the UK and ethical knowing: difficulties in conceptualising the ethics of nursing.

This paper's philosophical ideas are developed from a General Nursing Council for England and Wales Trust-funded study to explore nursing knowledge and wisdom and ways in which these can be translated into clinical practice and fostered in junior nurses. Participants using Carper's (1978) ways of knowing as a framework experienced difficulty conceptualizing a link between the empirics and ethics of nursing. The philosophical problem is how to understand praxis as a moral entity with intrinsic value when so much of value seems to be technical and extrinsic depending on desired ends. Using the Aristotelian terms poesis and praxis can articulate the concerns that the participants as well as Carper (1978) and Dreyfus (in Flyvbjerg, 1991) among others share that certain actions or ways of knowing important for nursing are being devalued and deformed by the importance placed on quantitative data and measurable outcomes. The sense of praxis is a moralized one and most of what nurses do is plausibly on any account of normative ethics a morally good thing; the articulation of the idea of praxis can go some way in showing how it is a part of the discipline of nursing. Nursing's acts as poesis can be a part of how practitioners come to have praxis as phronesis or practical wisdom. So to be a wise nurse, one needs be a wise person.

An internal morality of nursing: what it can and cannot do.

It has been claimed that there are certain acts that nurses as people practising nursing (nurses qua nurses) must never do because they are nurses and this is regardless of what the same agent (when not acting in the role of a nurse) should do; that certain actions are not part of proper nursing practice. The concept of an internal morality has been discussed in relation to medicine and has been used to ground the actions proper to medicine in a realist tradition. Although the concept of an internal morality of nursing is not explicitly mentioned in the literature the underpinning ideas about the proper practice of nursing based on philosophical realism I argue equate with it and a discussion of the method of an internal morality can help to understand how arguments against euthanasia (amongst other acts) related to the profession of nursing are far from clear. Ultimately, although the idea of particular acts proper to nurses qua nurses is not clear, the concept of an internal morality can help to get practitioners to see how the profession is tightly linked to moral actions, even so the hard problems in bioethics such as the morality of euthanasia remain hard for all and the easy ones easy for all.

Is there unity within the discipline?

This paper will examine a claim that nursing is united by its moral stance. The claim is that there are moral constraints on nurses' actions as people practising nursing (nurses qua nurses) and that they are in some way different from both what for now can be called standard morality and also different from the person's own moral views who also happens to be a nurse, hence the defining and unifying factor for nursing. I will begin by situating the claim within the broader area about the need for a definition to state features that are essential to all and only members of its class. This will highlight the fact that there are two distinct types of definition used by authors seeking to find a unity for nursing. One type of definition has to do with goals or purposes given to nursing and the other with ends discovered as nursing. But even if there are ends waiting to be discovered a particular practical concern is how we can have knowledge of them. I will suggest that knowledge by intuition is plausible but that as things currently stand in moral epistemology it will not provide the unifying ground for nursing. Then I will argue that in the latter approach to definition a certain account of human nature has been advanced in order to provide features that are there to be discovered and so not dependent on human beings for the definition or classification. However, such an attempt to define nursing cannot do what is wanted. Rather than the account of human nature grounding morality and doing so for nursing, the account of human nature itself relies upon a prior account of morality. Because of this it loses its supposed ground of unity for the profession. Nursing is not united by its moral stance especially if this is understood in a strong sense as unique moral stance, but as things currently stand in moral epistemology this is not necessarily a bad thing for practitioners or patients.