A Relational Approach to Implantable Cardioverter-Defibrillator Generator Replacement: An Integrative Review of the Role of Nursing in Shared Decision-Making.

BACKGROUND: Implantable cardioverter defibrillator (ICD) implantation rates are increasing as advances in heart failure and arrhythmia management progress. Consequently, the number of ICD generator replacements is rising and ICD replacement is an opportune time for shared decision-making (SDM). Nurses should have distinct roles and responsibilities in SDM processes. OBJECTIVES: To use a relational lens to localize the role of the nurse in SDM, and recommend ways in which nurses can be involved in SDM. METHODS: An integrative review of 17 articles was conducted to determine the role of nurses in SDM. RESULTS: Our analysis revealedfour themes that helped us articulate nurse involvement in SDM; knowledge as a basis for SDM, sharing power in the nurse-patient relationship, utilization of decisional support strategies, and communication. CONCLUSION: Our findings support the participation of nurses in SDM. Nursing implications are offered, specifically for the management of patients facing ICD replacement.

Perspectives on organ and tissue donation among Chinese Canadians.

Organ and tissue transplantation offers great potential for improving quality of life and reducing health care costs associated with end-stage organ failure. However, substantial and persistent shortages of organs and tissues for transplantation exist in Canada and there is a growing gap between those on transplant waiting lists and the organs available for transplantation. Every Canadian should have the opportunity to consider organ and tissue donation and transplantation in a culturally sensitive and respectful manner. During consultation with the Chinese Canadian community in Toronto, it was found that a clear understanding of the attitudes and values of Chinese Canadians regarding organ and tissue donation could assist health professionals in making ethnoculturally sensitive requests for donation to members of this community.

Families and heart transplantation: reversing the trajectory of end stage heart disease.

UNLABELLED: Family caregiving is central in the heart transplant (HT) process. METHOD: Using a constructivist grounded theory approach, study data were collected from 12 health professionals and 15 families in which one member was a HT recipient throughout three phases of the HT process. FINDINGS: Our interpretations suggest that family caregiving contributes to "reversing the downward trajectory" of end stage heart disease. This impacts the health of caregivers and disrupted family life. In some families, this caregiving work contributed to a smooth and uncomplicated recovery, while for others caregiving work was demanding and prolonged, or their loved one succumbed. Families reported that access to system-level supports for family caregiving varied. CONCLUSION: Family caregiving is an important factor in a successful recovery from HT. To ensure effective family caregiving, support should be available to family members in this role across all stages of the HT process.

Navigating towards a moral horizon: a multisite qualitative study of ethical practice in nursing.

This paper reports the results of a qualitative study of nurses' ethical decision-making. Focus groups of nurses in diverse practice contexts were used as a means to explore the meaning of ethics and the enactment of ethical practice. The findings centre on the metaphor ofa moral horizon--the horizon representing "the good" towards which the nurses were navigating.The findings suggest that currents within the moral climate of nurses' work significantly influence nurses' progress towards their moral horizon. All too often the nurses found themselves navigating against a current characterized by the privileging of biomedicine and a corporate ethos. Conversely, a current of supportive colleagues as well as professional guidelines and standards and ethics education helped them to move towards their horizon.The implications for nursing practice and for our understanding of ethical decision-making are discussed.

Challenges and opportunities in graduate nursing education by distributed learning in Canada and Brazil.

In this paper, the authors share their experience related to graduate nursing programs offered by distributed learning (DL) in Canada and Brazil. Although degrees offered by DL are often the subject of criticism, the authors' experience has been that learning outcomes have been very good. Nevertheless, a number of challenges and opportunities have been encountered including those associated with flexibility of the program, delivering practice courses at a distance, facilitating interaction, faculty workload and preparation and student support, Newer technologies that may assist in this effort are identified. Despite the challenges encountered, students rate the program highly and ongoing efforts are underway to ensure excellence of such flexible innovative graduate programs in nursing. The authors argue that despite the challenges, DL programs offer high quality graduate education that meets the needs of many nurses.

Managing chronic kidney disease in a nurse-run, physician-monitored clinic: the CanPREVENT experience.

The purpose of this study was to examine the nature of the care provided to people with chronic kidney disease within a larger study of nurse-run, physician-monitored clinics, as well as how patients, nurses, and nephrologists described their experience with the clinics. Interviews were conducted with 7 nurses, 5 physicians, and 23 patients. Data collection also entailed review of 40 randomly selected charts. Identified themes related to characteristics of the nurse, patient-centred care, health promotion, teaching, dealing with problems, time, protocols, consultation and referrals, clinic logistics, paperwork/documentation, and nurse-physician collaboration. Challenges and outcomes were also described as part of the experience with the clinic. Patients were actively engaged in self-management and reported high levels of satisfaction with care as well as improvements in selected outcomes. Overall, the perceptions of this model of care were positive and the approach warrants further exploration.

Nursing graduate supervision of theses and projects at a distance: issues and challenges.

Nursing graduate supervision of theses and projects at a distance is a new experience for many faculties. In our global and mobile society, nursing students frequently seek graduate programs that are geographically distant from their home communities. As options for nursing graduate education through distributive learning become increasingly available, the challenges for faculty to supervise graduate students at a distance pose issues and concerns. In this paper, key issues including difficulty deciding between a project and a thesis, difficulty identifying a supervisor, developing the mentoring relationship between the student and the supervisor, and conducting analysis at a distance are discussed. Strategies developed to address these challenges are presented and critiqued.

Indo-Canadian beliefs regarding organ donation.

CONTEXT: There is concern that a disproportionately high number of people of South Asian origin await transplantation in Canada. The donation rate is low in this population, and it is difficult to obtain good tissue matches. OBJECTIVE: To explore the values and beliefs regarding organ donation among Indo-Canadian people living in British Columbia. DESIGN: A naturalistic qualitative study was designed. Individual interviews and focus groups were held to collect data pertaining to beliefs regarding organ donation. SETTING: Lower Mainland of British Columbia, Canada. PARTICIPANTS: A total of 40 Indo-Canadian persons participated; a wide range of ages, religions, and backgrounds were represented. RESULTS: The major themes that emerged from the data related to context (including family/community, religion, trust in the healthcare system, and knowledge about organ donation); and values and beliefs (including intergenerational considerations, death and dying, and the organ donation process). Participants noted that people from their community were reluctant to discuss death and relatedissues such as organ donation. Although there was recognition of the importance of individual decision making pertaining to organ donation, the participants believed that family and community members also should be involved. CONCLUSIONS: Beliefs varied considerably among participants, and one should not make assumptions about the beliefs of any one individual based primarily on that individual's membership in an ethnocultural community.

Chinese Canadian beliefs toward organ donation.

The authors' purpose in this study is to explore the values and beliefs regarding organ donation of Chinese Canadians. Data collection involved individual interviews (n = 15) and focus groups. The major organizing categories were the importance of context, and values and beliefs. The context included little knowledge about donation and possible influence of spiritual or cultural values. Lack of communication and the need to preserve an intact body were themes that emerged in relation to death and dying. In relation to organ donation, most participants thought it was "a noble deed," but fears about organ donation were similar to those reported in other studies. It is important to note the considerable diversity in beliefs among these participants.

What do ethics have to do with lifestyle change?

The discussions around health and health care suggest that many of the diseases prevalent in our society today are a direct result of lifestyle choices made by citizens. As these discussions continue, there is mounting evidence relating personal habits and lifestyle to major causes of mortality and morbidity. This evidence, coupled with the technological advances in health care and the resource allocation issues around health care delivery, is leading to a plethora of ethical concerns, questions and challenges. There has been little movement in society to begin to address these issues, although there is growing recognition that to solve these dilemmas a collaborative partnership of providers and consumers is required. In this paper, selected ethical issues associated with lifestyle and behaviour change are explored, with emphasis on the dilemmas that may occur as a result of differences in values. Various conceptual approaches to the issue of 'voluntariness' and several models for examining whether or not health risks are voluntary will be reviewed briefly. The use of interdisciplinary ethical decision making, and ongoing consumer and health care provider collaboration and dialogue, are emphasized as a means of beginning to solve these dilemmas.

Aboriginal beliefs about organ donation: some Coast Salish viewpoints.

A large number of Aboriginal people await transplantation, and reluctance to donate organs has been noted among Aboriginal people. The purpose of this study was to explore the values and beliefs regarding organ donation of Coast Salish people living in British Columbia, Canada. Interviews were held with 14 people (8 women and 6 men) ranging in age from 25 to 63 years. Contextual themes were: lack of trust, life in Aboriginal communities, and tension between contemporary and traditional perspectives. Themes pertaining to death and dying were: acceptance of fate, death routines/rituals, and body wholeness. Themes pertaining to organ donation were: "we don't talk about it," transfer of spirit, and helping others. There was considerable diversity in beliefs among participants, which suggests that the beliefs held by an individual Aboriginal person should not be assumed to reflect those of any specific Aboriginal community.

Navigating towards a moral horizon: a multisite qualitative study of ethical practice in nursing.

This paper reports the results of a qualitative study of nurses' ethical decision-making. Focus groups of nurses in diverse practice contexts were used as a means to explore the meaning of ethics and the enactment of ethical practice. The findings centre on the metaphor of a moral horizon--the horizon representing "the good" towards which the nurses were navigating. The findings suggest that currents within the moral climate of nurses' work significantly influence nurses' progress towards their moral horizon. All too often, the nurses found themselves navigating against a current characterized by the privileging of biomedicine and a corporate ethos. Conversely, a current of supportive colleagues as well as professional guidelines and standards and ethics education helped them to move towards their horizon. The implications for nursing practice and for our understanding of ethical decision-making are discussed.

The supply of organs for transplantation: issues and challenges.

The success of organ transplantation has been well documented, with improvements in quality of life and cost-effectiveness being notable outcomes of the therapy. In this paper, we focus on the major issues and challenges related to the shortage of solid organs available for transplantation. The reasons for the organ shortage are complex and multifaceted. Fewer motor vehicle accident deaths, public perceptions about organ donation, attitudes of health professionals, knowledge of health professionals regarding organ donation, donor identification processes, family consent rates, and ethnocultural considerations are all issues that are important to consider in addressing the shortage.

Leadership for ethical policy and practice (LEPP): participatory action project.

Within Canada's fast-paced, ever-changing healthcare environment, providers are experiencing difficulty practising according to their professional ethical standards, leading many to experience moral or ethical distress. Limited attention has been paid to improvements in the ethical climate in healthcare settings in research focusing on nurses' workplaces. In this three-year study, we focused on how the ethical climate in healthcare delivery can be improved and how the use of participatory action research methods can lead to continued enhancements and lasting changes in services delivery. Together, we developed strategies for taking action, aimed at improving the quality of the work environment. This action involved both nurses in direct care and those in key leadership positions (CNOs or their equivalents). Through the active participation of those for whom the research-based change was intended, these strategies were tested in various sites across British Columbia and can be used as templates or designs for use in other settings. A key component of the success of the projects and action plans that were created was the integral involvement of nurse leaders through all phases.

Genes and geneticization? The social construction of autosomal dominant polycystic kidney disease.

Critics of the new genetics argue that contemporary understandings of health and illness are becoming increasingly 'geneticized.' Salient implications of this critique are explored here within the context of Autosomal Dominant Polycystic Kidney Disease (PKD), a life-threatening genetic disease that causes fluid-filled cysts in the kidneys and progressive loss of renal function. Although PKD is very common, public awareness of the disease remains low and there is little clinical emphasis on hereditary aspects. Drawing upon qualitative interviews with 16 healthcare providers, 13 patients and 15 family members, this paper examines the social construction and clinical management of PKD. In particular, interviewees' perceptions of the role of genetics in PKD and views on presymptomatic testing are considered. Finding little impetus toward early diagnosis and/or presymptomatic identification of mutation carriers, we conclude that careful empirical study of PKD (or other neglected hereditary conditions) contributes new insights into factors mitigating geneticization.

Ethical practice in nursing: working the in-betweens.

BACKGROUND: While contemporary ethical theory is of tremendous value to nursing, the extent to which such theory has been informed by the concerns and practices of nurses has been limited. PURPOSE: With a view to complementing extant ethical theory, a study was undertaken to explore, from the perspective of nurses, the meaning of ethics and the enactment of ethical practice in nursing. DESIGN AND METHODS: Located in the interpretive/constructivist paradigm, using an emergent design, this inquiry employed focus groups to collect the data. Eighty-seven nurses from a wide range of practice settings were interviewed in 19 focus groups of three to nine nurses each. FINDINGS: The nurses described ethics in their practice as both a way of being and a process of enactment. They described drawing on a wide range of sources of moral knowledge in a dynamic process of developing awareness of themselves as moral agents. Enacting moral agency involved working in a shifting moral context, and working in-between their own values and those of the organizations in which they worked, in-between their own values and those of others, and in-between competing values and interests. CONCLUSIONS: Analysis of the experiences and concerns of the nurses offered new understanding of ethics in nursing and direction for the development of ethical theory pertinent to nursing practice.

Challenges and opportunities in graduate nursing education by distributed learning in Canada and Brazil / Desafios e oportunidades na educação de pós-graduação em enfermagem por aprendizagem distribuída no Canadá e Brasil / Retos y oportunidades en la educación de postgrado en enfermería por aprendizaje distribuido en Canadá y Brasil

In this paper, the authors share their experience related to graduate nursing programs offered by distributed learning (DL) in Canada and Brazil. Although degrees offered by DL are often the subject of criticism, the authors’ experience has been that learning outcomes have been very good. Nevertheless, a number of challenges and opportunities have been encountered including those associated with flexibility of the program, delivering practice courses at a distance, facilitating interaction, faculty workload and preparation and student support, Newer technologies that may assist in this effort are identified. Despite the challenges encountered, students rate the program highly and ongoing efforts are underway to ensure excellence of such flexible innovative graduate programs in nursing. The authors argue that despite the challenges, DL programs offer high quality graduate education that meets the needs of many nurses.

Neste trabalho, os autores partilham suas experiências na pós-graduação em Enfermagem no Canadá e Brasil oferecidas por meio de aprendizagem distribuída (AD). Embora a AD seja freqüentemente objeto de críticas, a experiência dos autores tem sido de resultados positivos. No entanto, uma série de desafios e oportunidades é discutida, incluindo: flexibilidade do programa, possibilidade de oferecimento de cursos práticos à distância, necessidade de facilitar a interação professor/alunos, sobrecargade trabalho dos docentes, preparo dos docentes para este tipo de atividade e apoio aos estudantes. Novas tecnologias que podem apoiar o desenvolvimento da AD são apresentadas. Apesar dos desafios identificados, os estudantes avaliam positivamente a AD e esforços tem sido feitos para assegurar, de modo inovativo e flexível, a excelência de programas de pós-graduação em enfermagem. Os autores argumentam que apesar dos desafios existentes, os programas de AD oferecem alta qualidade para o ensino de pós-graduação na área de enfermagem e atendem às necessidades de muitos enfermeiros.

En este artículo, los autores comparten sus experiencias de programas de postgrado de enfermería, ofrecidos en Canadá y Brasil, el aprendizaje distribuido (AD). Aunque el AD sea objeto de críticas, la experiencia de los autores ha demostrado resultados positivos del aprendizaje. Sin embargo, se han encontrado algunos retos y oportunidades: los relacionados con laflexibilidad del programa, la posibilidad de ofrecimiento de cursos prácticos a distancia, la necesidad de facilitar la interacción profesor/estudiante y apoyo a los estudiantes, la sobrecarga de trabajo del profesor y la necesidad de su preparación para esta actividad, Nuevas tecnologías que pueden apoyar el desarrollo del AD son presentadas. A pesar de los desafíos identificados, los estudiantes evaluaron positivamente el AD y se esforzaron para asegurar, de manera innovadora y flexible, la excelencia de postgrado en enfermería. Los autores sostienen que a pesar de los desafíos, los programas de postgrado con el AD ofrecen educación de alta calidad y cumple las necesidades de muchas enfermeras.