Social Determinants of Hallway Bed Use.

INTRODUCTION: Hallway beds in the emergency department (ED) produce lower patient satisfaction and inferior care. We sought to determine whether socioeconomic factors influence which visits are assigned to hallway beds, independent of clinical characteristics at triage. METHODS: We studied 332,919 visits, across 189,326 patients, to two academic EDs from 2013-2016. We estimated a logistic model of hallway bed assignment, conditioning on payor, demographics, triage acuity, chief complaint, patient visit frequency, and ED volume. Because payor is not generally known at the time of triage, we interpreted it as a proxy for other observable characteristics that may influence bed assignment. We estimated a Cox proportional hazards model of hallway bed assignment on length of stay. RESULTS: Median patient age was 53. 54.0% of visits were by women. 42.1% of visits were paid primarily by private payors, 37.1% by Medicare, and 20.7% by Medicaid. A total of 16.2% of visits were assigned to hallway beds. Hallway bed assignment was more likely for frequent ED visitors, for lower acuity presentations, and for psychiatric, substance use, and musculoskeletal chief complaints, which were more common among visits paid primarily by Medicaid. In a logistic model controlling for these factors, as well as for other patient demographics and for the volume of recent ED arrivals, Medicaid status was nevertheless associated with 22% greater odds of assignment to a hallway bed (odds ratio 1.22, [95% confidence interval, CI, 1.18-1.26]), compared to private insurance. Visits assigned to hallway beds had longer lengths of stay than roomed visits of comparable acuity (hazard ratio for departure 0.91 [95% CI, 0.90-0.92]). CONCLUSION: We find evidence of social determinants of hallway bed use, likely involving epidemiologic, clinical, and operational factors. Even after accounting for different distributions of chief complaints and for more frequent ED use by the Medicaid population, as well as for other visit characteristics known at the time of triage, visits paid primarily by Medicaid retain a disproportionate association with hallway bed assignment. Further research is needed to eliminate potential bias in the use of hallway beds. [West J Emerg Med. 2020;21(4)949-958.].

Student voice - Questioning others as a child's advocate.

RECENTLY I WAS involved in a situation in which I was asked to assist two staff nurses in an invasive procedure with a young child. Initially, I held the child down as instructed to do by the staff nurses. The child became distressed, so I asked the nurses to stop the procedure and to give the child a break.

Isolamento social, sociabilidades e redes sociais de cuidados / Social isolation, sociability and social care networks

Este trabalho examina, em caráter exploratório, experiências de isolamento social vividas por indivíduos portadores de hanseníase, internados na ex-colônia Tavares de Macedo, em Itaboraí, onde foram mantidas da década de 1930 até os dias de hoje, para problematizar noções sobre segregação e discriminação social presentes nesse meio. Para tanto, examina sociabilidades e redes sociais de cuidados estabelecidas na vida em comum nessa "ex-colônia de leprosos", quase sempre como alternativas às condições oferecidas pelos sistemas públicos de proteção social. Faz isso com base em narrativas de alguns desses sujeitos, vistos em suas diferenças - nas interseções das relações por sexos, classes, raças/etnias, gerações, e também por religiões e graus de escolaridade. Recorre à história oral, modo de oferecer novas interpretações qualitativas de processos histórico-sociais evidenciados nessas sociabilidades e redes, nem sempre visíveis como formas singulares de proteção social da vida em comum.

This exploratory work examines the social isolation experienced by individuals with leprosy admitted to the former colony Tavares de Macedo, Itaboraí, where they were kept from the 1930s until the present day, to question notions of segregation and social discrimination present in this environment. So it analyzes sociabilities and social care networks established in the common life in this "ex-leper colony," usually as alternatives to the conditions offered by the public systems of social protection. The work is based on stories of some of the subjects, seen in their differences - at intersection of gender relations, classes, races/ethnicities, generations and also by religions and educational backgrouns. It adopts the oral history, so as to offer new qualitative interpretations of social and historical processes shown in these networks and sociability, not always visible as unique forms of social protection of life in groups.

Dare we speak of ethics? Attending to the unsayable amongst nurse leaders.

There is increasing emphasis on the need for collaboration between practice and academic leaders in health care research. However, many problems can arise owing to differences between academic and clinical goals and timelines. In order for research to move forward it is important to name and address these issues early in a project. In this article we use an example of a participatory action research study of ethical practice in nursing to highlight some of the issues that are not frequently discussed and we identify the impact of things not-named. Further, we offer our insights to others who wish to be partners in research between academic and practice settings. These findings have wide implications for ameliorating misunderstandings that may develop between nurse leaders in light of collaborative research, as well as for participatory action research.

Battlefield conditions: different environment but the same duty of care.

Using an interpretative research approach to ethical and legal literature, it is argued that nursing in the battlefield is distinctly different to civilian nursing, even in an emergency, and that the environment is so different that a duty of care owed by military nurses to wounded soldiers should not apply. Such distinct differences in wartime can override normal peacetime professional ethics to the extent that the duty of care owed by military nurses to their patients on the battlefield should not exist. It is also argued that as military nurses have legal and professional obligations to care for wounded soldiers on the battlefield, this obligation conflicts with following military orders, causing a dual loyalty conflict. This is because soldiers are part of the 'fighting force' and must be fit to fight and win the battle. This makes them more of a commodity rather than individual persons with distinct health care needs.

Dignity of older people in a nursing home: narratives of care providers.

The purpose of this study was to illuminate the ethically difficult situations experienced by care providers working in a nursing home. Individual interviews using a narrative approach were conducted. A phenomenological-hermeneutic method developed for researching life experience was applied in the analysis. The findings showed that care providers experience ethical challenges in their everyday work. The informants in this study found the balance between the ideal, autonomy and dignity to be a daily problem. They defined the culture they work in as not supportive. They also thought they were not being seen and heard in situations where they disagree with the basic values of the organization. The results are discussed in terms of Habermas's understanding of modern society. Care settings for elderly people obviously present ethical challenges, particularly in the case of those suffering from dementia. The care provider participants in this study expressed frustration and feelings of powerlessness. It is possible to understand their experiences in terms of Habermas's theory of modern society and the concept of the system's colonization of the life world.

Professional ethics: beyond the clinical competency.

Assessment of clinical competency in professional roles especially in crucial situations can improve the nursing profession. This qualitative research was conducted to determine the process of acquiring clinical competency by nurses in its cultural context and within the health care delivery system in Iran. This study, using grounded theory methodology, took place in universities and hospitals in Tehran. Nurses (36) included nurse managers, tutors, practitioners, and members of the Iranian Nursing Organization. Simultaneous data collection and analysis took place using participant semistructured interviews. Three categories emerged: (a) personal characteristics such as philanthropy, strong conscience, being attentive, accepting responsibility, being committed to and respecting self and others; (b) care environment including appropriate management systems, in-service training provision, employment laws, and control mechanisms, suitable and adequate equipment; and (c) provision of productive work practices including love of the profession, critical thinking, nursing knowledge, and professional expertise. Professional ethics has emerged as the core variable that embodies concepts such as commitment, responsibility, and accountability. Professional ethics guarantees clinical competency and leads to the application of specialized knowledge and skill by nurses. The results can be used to form the basis of guiding the process of acquiring clinical competency by nurses using a systematic process.

Registered nurses' perceptions of moral distress and ethical climate.

Moral distress is a phenomenon of increasing concern in nursing practice, education and research. Previous research has suggested that moral distress is associated with perceptions of ethical climate, which has implications for nursing practice and patient outcomes. In this study, a randomly selected sample of registered nurses was surveyed using Corley's Moral Distress Scale and Olson's Hospital Ethical Climate Survey (HECS). The registered nurses reported moderate levels of moral distress intensity. Moral distress intensity and frequency were found to be inversely correlated with perceptions of ethical climate. Each of the HECS factors (peers, patients, managers, hospitals and physicians) was found to be significantly correlated with moral distress. Based on these findings, we highlight insights for practice and future research that are needed to enhance the development of strategies aimed at improving the ethical climate of nurses' workplaces for the benefit of both nurses and patients.

Licensed nurses' perceptions of ethical climates in skilled nursing facilities.

This study examines the presence of ethical climates in skilled nursing facilities and identifies their antecedents (work group, job position, tenure). A cross-sectional survey design was implemented. A total of 359 facilities were selected in the Midwestern United States. Responses were received from nurses representing 100 of those facilities (28%). A total of 656 usable questionnaires were returned of the 3060 distributed (21.4% response rate). Descriptive statistics, confirmatory factor analysis, and multivariate and univariate analyses of variance were used. The results confirmed the presence of five ethical climates. Significant differences between registered and licensed practical nurses with regard to egoistic and independence ethical climates were found. Furthermore, nurses in management and non-management positions differed significantly in their perceptions of caring and egoistic climates. The results suggest incongruence in value perceptions and imply that researchers and practitioners have to direct efforts towards preventing and identifying reasons behind this.

An ethical framework for developing and sustaining a healthy workplace.

Acute and critical care nurses provide care that is intellectually challenging and physically demanding in environments that are often characterized by ethical concerns and dilemmas. As complex adaptive systems, these environments include nurses, physicians, social workers, chaplains, case managers, and administrators who interact together in situations of tremendous uncertainty and frequently in the face of professional or social disagreement about patient/family care, processes, and outcomes. Nurses' ability to identify and resolve concerns in such situations as part of a collaborative ethical climate is a significant retention factor and a hallmark of a healthy workplace. The purpose of this article is to describe a pluralist ethical framework that evolved from the formation of a healthy workplace and that may be integrated to sustain an ethical climate. Discussion of development of a healthy workplace employing participatory action research will be followed by a description of ethical theories supporting the framework and their relevance to creating and sustaining a healthy workplace and ethical practice environment. Finally, specific application examples of the ethical framework from nursing units' staff participatory action research studies will be presented.

Healthy workplaces and ethical environments: a staff nurse's perspective.

Healthy workplaces contribute to improved patient safety and job satisfaction. In the development of healthy workplace cultures, various frameworks have been offered as strategy guides. There has also been a growing body of evidence that ethical climates and education can positively influence patient safety and job satisfaction. Within an ethical context, the American Association of Critical-Care Nurses's Standards for Establishing and Sustaining Healthy Work Environments have been examined. It is proposed that the underpinnings of healthy workplace initiatives be built upon an ethical foundation that is apparent to staff nurses. The benefit of incorporation of an ethical context into workplace change is discussed. Evidence to support the proposal is cited and examples are given.

Enhancing ethical climates in nursing work environments.

In the current era of providing health care under pressure, considerable strain has been placed on nurses workplaces. Underneath the economic and organizational challenges prevalent in health-care delivery today are important values that shape the ethical climate in workplaces and affect the well-being of nurses, managers, patients and families. In this article, the authors report on the outcomes of Leadership for Ethical Policy and Practice, a three-year participatory action research study involving nurses, managers and other health-care team members in organizations throughout British Columbia. By using an ethics lens to look at problems, participants brought ethical concerns out into the open and were able to gain new insights and identify strategies for action to improve the ethical climate. Nurse leader support was essential for initiating and sustaining projects at six practice sites.

Reflexivity, knowledge and ecological awareness: premises for responsible action in the hospital work environment.

The article aims to analyze the interface of reflexivity, knowledge and ecologic awareness in the context of hospital work, based on data collected in a qualitative case study carried out at a public hospital. Field observation data and interviews are discussed in the light of sociologic and philosophic references. Workers expressed the interface between knowledge and action, in which there is a cycle of lack of knowledge, automatism in the actions and lack of environmental awareness, posing limits to individual awareness and to responsibility towards environmental preservation. Increased debate and education, including the environmental issue, are needed in the context of hospital work. Although hospital work is reflexively affected by the environmental problem, that does not guarantee the reorientation of practices and responsible action towards the environment.

Ethical behaviours in clinical practice among Mexican health care workers.

The objective of this study was to describe the cultural domain of ethical behaviours in clinical practice as defined by health care providers in Mexico. Structured interviews were carried out with 500 health professionals employed at the Mexican Institute of Social Security in Mexico City. The Smith Salience Index was used to evaluate the relevance of concepts gathered from the free listings of the interviewees. Cluster analysis and factor analysis facilitated construction of the conceptual categories, which the authors refer to as ;dimensions of ethical practice'. Six dimensions emerged from the analysis to define the qualities that comprise ethical clinical practice for Mexican health care providers: overall quality of clinical performance; working conditions that favour quality of care; use of ethical considerations as prerequisites for any health care intervention; values favouring teamwork in the health professional-patient relationship; patient satisfaction scores; and communication between health care providers and patients. The findings suggest that improved working conditions and management practices that promote the values identified by the study's participants would help to improve quality of care.

Nurse leaders as stewards at the point of service.

Nurse leaders, including clinical nurse educators, who exercise stewardship at the point of service, may facilitate practising nurses' articulation of their shared value priorities, including respect for persons' dignity and self-determination, as well as equity and fairness. A steward preserves and promotes what is intrinsically valuable in an experience. Theories of virtue ethics and discourse ethics supply contexts for clinical nurse educators to clarify how they may facilitate nurses' articulation of their shared value priorities through particularism and universalism, as well as how they may safeguard nurses' self-interpretation and discursive reasoning. Together, clinical nurse educators and nurses may contribute to management decisions that affect the point of service, and thus the health care organization.