Women's autonomy for managing labour pain in a relational context: An interpretive description study.

AIM: To describe how women perceived relational autonomy for decision-making during childbirth pain and illuminate influencing factors. BACKGROUND: Most women report challenging pain during birth. Circumstances can affect their ability to engage in pain management decisions. DESIGN: We used an interpretative description approach to conduct this study. METHOD: A purposive sample of ten women who reported pain during childbirth participated in semi-structured interviews. The study was conducted between July 2019 and November 2020 and reported according to the COREQ checklist. RESULTS: Circumstances during childbirth, such as women's expectations and relationships, influenced their efforts to engage in relational autonomy. Care providers dealt with the unpredictability of childbirth and challenges with pain management using decision-making practices that could disrupt women's expectations, undermine women's trust, demonstrate disrespect for women and rely on inadequate communication. Women who felt dependent on others were less likely to participate in decision-making. When care providers' perceptions about pain differed from women's reports of pain, participants became distressed because care providers did not acknowledge their subjective pain experiences. CONCLUSIONS: Women regarded their relationships and communication with care providers as foundational to relational autonomy in decision-making about pain management during childbirth. RELEVANCE TO CLINICAL PRACTICE: Study findings can support care providers' considerations of the complexity of childbirth pain and factors affecting women's relational autonomy in decision-making about pain. In particular, the findings highlight the importance of women's expectations and care providers' recognition of women's experiences of pain. PATIENT OR PUBLIC CONTRIBUTION: Women who shared their stories of childbirth pain contributed to the data collected. The chief nursing officers in the data collection setting facilitated the recruitment and data collection.

Risking vulnerability: Enacting moral agency in the is/ought gap in mental health care.

AIM: To explore how healthcare providers in acute care mental health settings navigate ethically challenging situations, enact moral agency, practice in congruence with ethical standards and mitigate moral distress (MD). DESIGN: Grounded theory, a qualitative methodology. METHODS: Over 18 months between 2015 and 2017, we reviewed documents, conducted observations and interviewed multidisciplinary participants (N = 27) from inpatient and emergency departments. Participants either provided direct care (N = 14) or were in leadership positions (N = 13). Data were analysed iteratively using constant comparison, coding, memoing and theorizing, which continued until saturation was reached in July 2016. FINDINGS: The basic social process of how healthcare professionals enacted moral agency, Risking Vulnerability, occurred in the context of Systemic Inhumanity, a constant source of MD. Participants Risked Vulnerability, balancing professional obligations, clinical expertise and organizational processes with their own vulnerability in the system as they strove to practice ethically. Risking Vulnerability was composed of Pushing Back, Working Through Team Relationships and Struggling with Inhumanity. CONCLUSION: Healthcare professionals' moral agency occurred at the nexus of structure (organizational constraints) and agency (persons). Given this, interventions for MD should be directed at all levels of healthcare to support moral agency, promote ethical practice and improve care. IMPACT: Sociopolitical elements such as austerity measures undermined ethical practice at the level of direct care. Enactment of moral agency is dynamic, influencing experiences of MD: participants supported by leadership or colleagues to enact moral agency noted that they were not stuck in MD. Interventions supporting moral agency throughout the healthcare system are necessary to mitigate experiences of MD. Findings enhance our understanding of the role of action in the experience of MD.

Moral neutralization: Nurses' evolution in unethical climate workplaces.

INTRODUCTION: Good quality of care is dependent on nurses' strong clinical skills and moral competencies, as well. While most nurses work with high moral standards, the moral performance of some nurses in some organizations shows a deterioration in their moral sensitivity and actions. The study reported in this paper aimed to explore the experiences of nurses regarding negative changes in their moral practice. MATERIALS AND METHODS: This was a qualitative study utilizing an inductive thematic analysis approach, which was conducted from February 2017 to September 2019. Twenty-five nurses participated in semi-structured interviews. RESULTS: The main theme that emerged from our analysis was one of moral neutralization in the context of an unethical moral climate. We found five sub-themes, including: (1) feeling discouraged; (2) normalization; (3) giving up; (4) becoming a justifier; and (5) moral indifference. CONCLUSIONS: Unethical moral climates in health organizations can result in deterioration of morality in nurses which can harm both patients and health systems. Some unethical behaviors in nurses can be explained by this process.

Non-pharmacological interventions during childbirth for pain relief, anxiety, and neuroendocrine stress parameters: A randomized controlled trial.

AIM: This study aimed to investigate the effect of warm shower hydrotherapy and perineal exercises with a ball on pain, anxiety, and neuroendocrine stress parameters during childbirth. METHODS: This randomized controlled trial was conducted with 128 women during childbirth, admitted for hospital birth in São Paulo, Brazil, from June 2013 to February 2014. The participants were randomly assigned into one of the following intervention groups: received warm shower hydrotherapy (GA); performed perineal exercises with a ball (GB); and combined intervention group, which received warm shower hydrotherapy and perineal exercises with a ball (GC) (n = 39). Pre-and post-intervention parameters were evaluated using visual analogue scales for pain and anxiety, and salivary samples were collected for the stress hormones analysis. RESULTS: Pain, anxiety, and epinephrine release decreased in the group performing perineal exercises with a ball (GB). ß-endorphin levels increased in this group (GB) after the intervention and showed significant difference in capacity to cause this effect (P = .007). However, no significant differences were observed in cortisol, epinephrine, and norepinephrine levels. CONCLUSIONS: Warm showers and perineal exercises could be considered as adjunct therapy for women suffering from pain, anxiety, and stress during childbirth. Clinical Trial Registry RBR-84xprt.

Moving from conceptual ambiguity to knowledgeable action: using a critical realist approach to studying moral distress.

Moral distress is a phenomenon that has been receiving increasing attention in nursing and other health care disciplines. Moral distress is a concept that entered the nursing literature - and subsequently the health care ethics lexicon - in 1984 as a result of the work done by American philosopher and bioethicist Andrew Jameton. Over the past decade, research into moral distress has extended beyond the profession of nursing as other health care disciplines have come to question the impact of moral constraint on individual practitioners, professional practice, and patient outcomes. Along with increased interest in the phenomenon of moral distress have come increasing critiques - critiques that in their essence point to a serious lack of conceptual clarity in the definition, study, and application of the concept. Foundational to gaining conceptual clarity in moral distress in order to develop strategies to prevent and ameliorate the experience is a careful revisiting of the epistemological assumptions underpinning our knowledge and use of the concept of moral distress. It is our contention that the conceptual challenges reveal flaws in the original understanding of moral distress that are based on an epistemological stance that holds a linear conception of cause and effect coupled with a simplistic perspective of 'constraint' and 'agency'. We need a more nuanced approach to our study of moral distress such that our ontological and epistemological stances help us to better appreciate the complexity of moral agents acting in organizational contexts. We believe that critical realism offers such a nuanced approach.

'Underclassism' and access to healthcare in urban centres.

In this article, we draw on findings from an ethnographic study that explored experiences of healthcare access from the perspectives of Indigenous and non-Indigenous patients seeking services at the non-urgent division of an urban emergency department (ED) in Canada. Our aim is to critically examine the notion of 'underclassism' within the context of healthcare in urban centres. Specifically, we discuss some of the processes by which patients experiencing poverty and racialisation are constructed as 'underclass' patients, and how assumptions of those patients as social and economic Other (including being seen as 'drug users' and 'welfare dependents') subject them to marginalisation, discrimination, and inequitable treatment within the healthcare system. We contend that healthcare is not only a clinical space; it is also a social space in which unequal power relations along the intersecting axes of 'race' and class are negotiated. Given the largely invisible roles that healthcare plays in controlling access to resources and power for people who are marginalised, we argue that there is an urgent need to improve healthcare inequities by challenging the taken-for-granted assumption that healthcare is equally accessible for all Canadians irrespective of differences in social and economic positioning.

A Precarious Journey: Nurses from the Philippines Seeking RN Licensure and Employment in Canada.

Increasingly, internationally educated nurses (IENs) from developing countries are seeking RN licensure and employment in Canada. Despite efforts to support their integration into the nursing workforce, a significant number never achieve integration. To explore this phenomenon, the authors use ethnographic methods informed by postcolonial feminism and relational ethical theory to examine the experiences of nurses educated in the Philippines as they seek Canadian RN licensure and employment. The study's focus on a journey that begins in the Philippines and continues in Canada adds an important temporal dimension located in tensions within and between the contexts of regulatory and immigration policies. The findings illuminate the dual challenge of being a new arrival in the country and being an IEN pursuing the Canadian RN credential. Additionally, the findings deepen our understanding of the dominant political, ideological, and social values, both in the Philippines and in Canada, that shape this experience.

De plus en plus, des infirmières et infirmiers diplômés à l'étranger (IIDE) provenant de pays en développement cherchent à obtenir une accréditation d'infirmière ou infirmier autorisé (IA) afin de pouvoir se trouver un emploi au Canada. Malgré les efforts déployés pour soutenir leur intégration au sein de la profession infirmière, un nombre important d'entre elles et d'entre eux ne réussissent pas à s'intégrer. Dans le but d'étudier ce phénomène, les auteures de la présente étude ont utilisé les méthodes de l'ethnographie adaptées au point de vue du féminisme postcolonial et de la théorie de l'éthique relationnelle afin d'analyser l'expérience que vivent les IIDE des Philippines dans le cadre de leurs démarches pour l'obtention d'une accréditation d'IA et d'un emploi au Canada. Mettant l'accent sur un parcours qui commence aux Philippines et se poursuit au Canada, l'étude ajoute une importante dimension temporelle aux tensions qui existent à l'intérieur des différents contextes réglementaires et des politiques d'immigration, de même qu'entre ceux-ci. Les constatations des auteures mettent en lumière le double défi que doivent relever les IIDE, soit celui d'être des nouveaux arrivants et celui de devoir obtenir une accréditation d'IA canadienne. L'étude contribue également à approfondir notre compréhension des valeurs sociales, idéologiques et politiques dominantes aux Philippines et au Canada, lesquelles ont façonné les expériences étudiées.

Evolving trends in nurse regulation: what are the policy impacts for nursing's social mandate?

We recognize a paradox of power and promise in the context of legislative and organizational changes in nurse regulation which poses constraints on nursing's capacity to bring voice and influence to pressing matters of healthcare and public policy. The profession is at an important crossroads wherein leaders must be well informed in political, economic and legislative trends to harness the profession's power while also navigating forces that may put at risk its central mission to serve society. We present a critical policy analysis of the impact of recent regulatory trends on what the International Council of Nurses considers nursing's three 'pillars' - the profession of nursing, socioeconomic welfare of nurses and nurse regulation. Themes surfacing from this analysis include regulatory discontinuity, a tightening of regulatory control, and an increasingly managerial governance culture. These themes illuminate insights and strategies required to renew and revitalize the social mandate of our profession amidst a climate of urgency in the questioning of nurse scholars with respect to the future of the profession. At this historic juncture, nurses must clearly understand the implications of legislative and organizational regulatory changes to ensure the profession contributes to full capacity in achieving health and health equity globally.

Almutairi's Critical Cultural Competence model for a multicultural healthcare environment.

The increasing demographic changes of populations in many countries require an approach for managing the complexity of sociocultural differences. Such an approach could help healthcare organizations to address healthcare disparities and inequities, and promote cultural safety for healthcare providers and patients alike. Almutairi's critical cultural competence (CCC) is a comprehensive approach that holds great promise for managing difficulties arising from sociocultural and linguistic issues during cross-cultural interactions. CCC has addressed the limitations of many other cultural competence approaches that have been discussed in the literature. Therefore, the purpose of this study is to define the construct of CCC and the theoretical components of the CCC.

Toward interventions to address moral distress: navigating structure and agency.

BACKGROUND: The concept of moral distress has been the subject of nursing research for the past 30 years. Recently, there has been a call to move from developing an understanding of the concept to developing interventions to help ameliorate the experience. At the same time, the use of the term moral distress has been critiqued for a lack of clarity about the concepts that underpin the experience. DISCUSSION: Some researchers suggest that a closer examination of how socio-political structures influence healthcare delivery will move moral distress from being seen as located in the individual to an experience that is also located in broader healthcare structures. Informed by new thinking in relational ethics, we draw on research findings from neuroscience and attachment literature to examine the reciprocal relationship between structures and agents and frame the experience of moral distress. CONCLUSION: We posit moral distress as a form of relational trauma and subsequently point to the need to better understand how nurses as moral agents are influenced by-and influence-the complex socio-political structures they inhabit. In so doing, we identify this reciprocity as a framework for interventions.

Online Modules to Alleviate Burnout and Related Symptoms Among Interdisciplinary Staff in Long-Term Care: A Pre-post Feasibility Study.

BACKGROUND: The rising trend of providing palliative care to residents in Canadian long-term care facilities places additional demands on care staff, increasing their risk of burnout. Interventions and strategies to alleviate burnout are needed to reduce its impact on quality of patient care and overall functioning of healthcare organizations. AIM: To examine the feasibility of implementing online modules with the primary goal of determining recruitment and retention rates, completion time and satisfaction with the modules. A secondary goal was to describe changes in burnout and related symptoms associated with completing the modules. SETTING: This single-arm, nonrandomized feasibility study was conducted in five long-term care sites of a publicly-funded healthcare organization in Vancouver, British Columbia, Canada. Eligible participants were clinical staff who worked at least 1 day per month. RESULTS: A total of 103 study participants consented to participate, 31 (30.1%) of whom were lost to follow-up. Of the remaining 72 participants, 64 (88.9%) completed the modules and all questionnaires. Most participants completed the modules in an hour (89%) and found them easy to understand (98%), engaging (84%), and useful (89%). Mean scores on burnout and secondary traumatic stress decreased by .9 (95% CI: .1-1.8; d = .3) and 1.4 (95% CI: .4-2.4; d = .4), respectively; mean scores on compassion satisfaction were virtually unchanged. CONCLUSIONS: Modules that teach strategies to reduce burnout among staff in long-term care are feasible to deliver and have the potential to reduce burnout and related symptoms. Randomized controlled trials are needed to assess effectiveness and longer-term impact.

Closing the health equity gap: evidence-based strategies for primary health care organizations.

INTRODUCTION: International evidence shows that enhancement of primary health care (PHC) services for disadvantaged populations is essential to reducing health and health care inequities. However, little is known about how to enhance equity at the organizational level within the PHC sector. Drawing on research conducted at two PHC Centres in Canada whose explicit mandates are to provide services to marginalized populations, the purpose of this paper is to discuss (a) the key dimensions of equity-oriented services to guide PHC organizations, and (b) strategies for operationalizing equity-oriented PHC services, particularly for marginalized populations. METHODS: The PHC Centres are located in two cities within urban neighborhoods recognized as among the poorest in Canada. Using a mixed methods ethnographic design, data were collected through intensive immersion in the Centres, and included: (a) in-depth interviews with a total of 114 participants (73 patients; 41 staff), (b) over 900 hours of participant observation, and (c) an analysis of key organizational documents, which shed light on the policy and funding environments. RESULTS: Through our analysis, we identified four key dimensions of equity-oriented PHC services: inequity-responsive care; trauma- and violence-informed care; contextually-tailored care; and culturally-competent care. The operationalization of these key dimensions are identified as 10 strategies that intersect to optimize the effectiveness of PHC services, particularly through improvements in the quality of care, an improved 'fit' between people's needs and services, enhanced trust and engagement by patients, and a shift from crisis-oriented care to continuity of care. Using illustrative examples from the data, these strategies are discussed to illuminate their relevance at three inter-related levels: organizational, clinical programming, and patient-provider interactions. CONCLUSIONS: These evidence- and theoretically-informed key dimensions and strategies provide direction for PHC organizations aiming to redress the increasing levels of health and health care inequities across population groups. The findings provide a framework for conceptualizing and operationalizing the essential elements of equity-oriented PHC services when working with marginalized populations, and will have broad application to a wide range of settings, contexts and jurisdictions. Future research is needed to link these strategies to quantifiable process and outcome measures, and to test their impact in diverse PHC settings.

Preserving the self: the process of decision making about hereditary breast cancer and ovarian cancer risk reduction.

Women who carry BRCA1 or BRCA2 (BRCA1/2) gene mutations have up to an 88% lifetime risk of breast cancer and up to a 65% lifetime risk of ovarian cancer. Strategies to address these risks include cancer screening and risk-reducing surgery (i.e., mastectomy and salpingo-oophorectomy). We conducted a grounded theory study with 22 BRCA1/2 mutation-carrier women to understand how women make decisions about these risk-reducing strategies. Preserving the self was the overarching decision-making process evident in the participants' descriptions. This process was shaped by contextual conditions including the characteristics of health services, the nature of hereditary breast and ovarian cancer risk-reduction decisions, gendered roles, and the women's perceived proximity to cancer. The women engaged in five decision-making styles, and these were characterized by the use of specific decision-making approaches. These findings provide theoretical insights that could inform the provision of decisional support to BRCA1/2 carriers.

Access to primary care from the perspective of Aboriginal patients at an urban emergency department.

In this article, we discuss findings from an ethnographic study in which we explored experiences of access to primary care services from the perspective of Aboriginal people seeking care at an emergency department (ED) located in a large Canadian city. Data were collected over 20 months of immersion in the ED, and included participant observation and in-depth interviews with 44 patients triaged as stable and nonurgent, most of whom were living in poverty and residing in the inner city. Three themes in the findings are discussed: (a) anticipating providers' assumptions; (b) seeking help for chronic pain; and (c) use of the ED as a reflection of social suffering. Implications of these findings are discussed in relation to the role of the ED as well as the broader primary care sector in responding to the needs of patients affected by poverty, racialization, and other forms of disadvantage.

Commentary: Exploring the Intersections between Bullying and Racism in Nursing.

Although bullying and racism are often explored separately in nursing literature, this commentary explores how bullying and racism intersect with each other. It emphasizes the importance of clearly understanding the meaning of each concept and argues that a focus on the intersectionality between the two ensures that bullying and racism are addressed not only at the intra- and interpersonal levels but also at the structural level. The authors ask themselves and their readers to reflect on posed questions and to make a commitment not to "do nothing" but instead to "do something."

Understanding childbirth pain in Brazilian women: A qualitative descriptive study.

BACKGROUND: The pain associated with childbirth is a cause of severe pain, and the literature suggests that it can be influenced by psychosocial influences, the environment, and cognitive processes, creating the overall experience of childbirth. Therefore, the investigation of women's childbirth pain experience is essential. AIM: The purpose of this study is to understand women's childbirth pain and determine which influences can contribute to building different experiences. METHOD: A qualitative descriptive approach was adopted to explore the women's childbirth pain experiences, by understanding the influences on their experiences. Data were collected through in-depth interviews with 21 women in a hospital setting in São Paulo, Brazil, and analysed by thematic analysis. RESULTS: Three major themes emerged from the analysis: (1) experiencing childbirth pain, (2) face-to-face with pain, and (3) empowerment needs. DISCUSSION: Many factors influence how Brazilian women manage pain and shape their experience during childbirth. The findings suggest that when women had a positive experience, they asked for minimal support, demonstrated balance, and expressed that the pain was manageable; when they had unfavourable experiences, they regarded pain as a threat and a punishment and associated it with unpleasant emotions. CONCLUSION: The results outlined concerns that should be addressed in the provision of specific, appropriate care for women, to support them in improving their experience during childbirth.

Exploring the Relational Intervention of Storytelling: A Qualitative Study of the Patient Stories Project in a Single ICU.

OBJECTIVES: Our study objective was to explore nurses' experiences of how the Patient Stories Project, an intervention consisting of garnering and sharing ICU survivor stories with the ICU team, influenced their perceptions of the value of their work and their nurse-patient relationships. DESIGN: This was a qualitative descriptive case study that used thematic analysis. SETTING: This study was conducted in a single, 34-bed adult ICU in a Canadian tertiary care teaching hospital, serving a mixed medical and surgical patient population and employing over 200 nurses. SUBJECTS: Semistructured focus groups with 12 ICU nurses were conducted between June 2019 and July 2019. INTERVENTION: The Patient Stories Project is a systematic process for collecting and sharing former patients' stories. On a regular basis, former ICU patients return to the ICU to say, "thank you," share their experiences, and tell their stories to staff. MEASUREMENTS AND MAIN RESULTS: Storytelling through the Patient Stories Project gives meaning to nurses' work and provides avenues for nurses to think about their work more positively. Key themes were as follows: 1) perspective taking, 2) emphasizing the value in caring, 3) providing positive closure, 4) engendering team belonging, and 5) building a sense of hope. CONCLUSIONS: This study addresses the Critical Care Societies Collaboratives "call to action" to create a healthy work environment. Nurse focus group participants articulated how an initiative such as the Patient Stories Project may augment the relational aspects of work that are important to nurses, as well as their patients and families. Our study results have implications for the importance of using storytelling as a relational strategy to protect against depersonalization and cynicism, elements of burnout.

Interrupting the cycle of bullying witnessed or experienced by nursing students: An ethical and relational action framework.

BACKGROUND: The prevalence of bullying experienced by nursing students continues to be a substantial concern for the profession, especially for nurse educators. It is also an issue in other health care professional programs. OBJECTIVES: To explore how educational institutions address bullying experienced by nursing and other health care professional students, with the goal of creating a set of procedures for reporting bullying if students witness or experience it during their education. DESIGN: Qualitative Description. Our central question was "What processes and resources do faculty members use when students disclose an experience related to bullying?" SETTINGS: Educational institutions in Western Canada. PARTICIPANTS: Nine faculty members and one staff member with a student service role from nursing and other health care profession programs. METHODS: Semi-structured interviews. RESULTS: We found significant variation in interviewees' conceptions of bullying and the policies, processes, and resources for addressing bullying within programs. We adopted an existing definition of bullying; designed a set of procedures focused on reporting mechanisms; and developed a guiding framework entitled Addressing Bullying in Nursing Education: An Ethical and Relational Action Framework. CONCLUSIONS: Nursing and other health care professional programs should ensure they have 1) clear and transparent procedures to report bullying 2) education about bullying for students and faculty.

Gatekeeping in cancer clinical trials in Canada: The ethics of recruiting the "ideal" patient.

BACKGROUND: Perspectives of clinical trial (CT) personnel on accrual to oncology CTs are relatively absent from the literature. This study explores CT personnel's experience recruiting patients to oncology CTs. METHODS: A qualitative study design was utilized. In-depth, individual interviews with 12 oncology CT personnel were conducted, including six CT nurses and six physician-investigators. Interviews were digitally recorded and transcribed verbatim. Data were subjected to thematic and ethical analysis to identify key concepts and themes. RESULTS: CT personnel reported considering two ethical commitments in CT recruitment: maintaining trial integrity and ensuring patient autonomy through obtaining informed consent. The process of gatekeeping emerged as a way to navigate these ethical commitments during CT accrual. Gatekeeping was influenced by: (a) perceptions of patients' personal suitability for a trial, and (b) healthcare resources and infrastructure. CT personnel's discernment of personal suitability was influenced by patients' cognitive and mental health status, language and cultural background, geographic location, family support, and disease status. Three structural factors impacted gatekeeping: complexity of CTs, consent process, and time limitations in the healthcare system. CT personnel experienced most factors as constraints to accrual and gaining patients' informed consent. CONCLUSION: CT personnel discussed navigating ethical challenges in CT recruitment by offering enrollment to specific patient populations, exacerbating other ethical tensions. Systems-level strategies are needed to address barriers to ethical CT recruitment. Future research should investigate the role of policies and/or tools (eg, decision aids) to support patients and CT personnel's discussions about CT participation, promote more ethical recruitment, and potentially increase accrual.