Developing a moral compass: Themes from the Clinical Ethics Residency for Nurses' final essays.

BACKGROUND: The Clinical Ethics Residency for Nurses was offered selectively to nurses affiliated with two academic medical centers to increase confidence in ethical decision-making. RESEARCH QUESTION/AIM: To discover how effective the participants perceived the program and if their goals of participation had been met. RESEARCH DESIGN: A total of 65 end-of-course essays (from three cohorts) were analyzed using modified directed content analysis. In-depth and recursive readings of the essays by faculty were guided by six questions that had been posed to graduates. ETHICAL CONSIDERATIONS: Institutional review board approval was granted for the duration of the program and its reporting period. Confidentiality was maintained via the use of codes for all evaluations including the essays and potentially identifying content redacted. FINDINGS: An umbrella theme emerged: participants had developed ethical knowledge and skills that provided a "moral compass to navigate the many gray areas of decision-making that confront them in daily practice." Six major themes corresponding to questions posed to the participants included the ability to advocate for good patient care; to support and empower colleagues, patients, and families; they experienced personal and professional transformation; they valued the multimodal nature of the program; and were using their new knowledge and skills in practice. However, they also recognized that their development as moral agents was an ongoing process. DISCUSSION: Findings support that enhancing nurse confidence in their moral agency with a multimodal educational approach that includes mentored practice in ethical decision-making, enhancing communication skills and role-play can mitigate moral distress. A majority found the program personally and professionally transformative. However, they recognized that ongoing ethics discussion involvement and supportive environments would be important in their continued development of ethical agency. CONCLUSION: Multimodal ethics education programs have potential to be transformative and enhance nurse confidence in their ethical decision-making.

The role of religious beliefs in ethics committee consultations for conflict over life-sustaining treatment.

Previous research has suggested that individuals who identify as being more religious request more aggressive medical treatment at end of life. These requests may generate disagreement over life-sustaining treatment (LST). Outside of anecdotal observation, however, the actual role of religion in conflict over LST has been underexplored. Because ethics committees are often consulted to help mediate these conflicts, the ethics consultation experience provides a unique context in which to investigate this question. The purpose of this paper was to examine the ways religion was present in cases involving conflict around LST. Using medical records from ethics consultation cases for conflict over LST in one large academic medical centre, we found that religion can be central to conflict over LST but was also present in two additional ways through (1) religious coping, including a belief in miracles and support from a higher power, and (2) chaplaincy visits. In-hospital mortality was not different between patients with religiously versus non-religiously centred conflict. In our retrospective cohort study, religion played a variety of roles and did not lead to increased treatment intensity or prolong time to death. Ethics consultants and healthcare professionals involved in these cases should be cognisant of the complex ways that religion can manifest in conflict over LST.

Developing Abilities to Navigate Through the Grey Zones in Complex Environments: Nurses' Reasons for Applying to a Clinical Ethics Residency for Nurses.

BACKGROUND AND PURPOSE: Nurses face complex ethical issues in practice and have to determine appropriate actions. An inability to conceptualize or follow a preferred course of action can give rise to moral uncertainty or moral distress. Both moral uncertainty and moral distress are problematic for nurses and their patients. A program designed to increase nurse confidence in moral decision making, the clinical ethics residency for nurses (CERN), was offered selectively to nurses affiliated with two academic medical centers. This is a report of the analysis of their application essays. DESIGN: Over a 3-year period, 67 application essays were analyzed using conventional content analysis. Applicants comprised one third advanced practice nurses (APNs) and two thirds staff nurses. They were asked to describe their reasons for interest in the CERN and how they would apply the knowledge gained. METHODS: For conventional content analyses, no theoretical presumptions are used; rather, codes are identified from the data in an iterative manner and eventually collapsed into themes. Initially, broad themes were identified by the CERN team. Subsequently, in-depth and recursive readings were completed by a subset of three members, resulting in refinement of themes and subthemes. FINDINGS: The overarching theme identified was "developing abilities to navigate through the 'grey zones' in complex environments." Three subthemes were: (a) nurses encountering patients who are chronically critically ill, culturally diverse, and presenting with complex circumstances; (b) nurses desiring enhanced ethics knowledge and skills to improve quality of care, understand different perspectives, and act as a resource for others; and (c) nurses supporting and facilitating patient-centered ethical decision making. CONCLUSIONS: Findings are consistent with those appearing in the international literature but provide a more cohesive and comprehensive account than previously, and hold promise for the development of educational and policy strategies to address moral distress and uncertainty. CLINICAL RELEVANCE: This study is relevant to clinical practice in its verification of the need nurses have for ethics knowledge, skill refinement, and application through communication. These findings affirmed the challenge that nurses feel in communicating their ethical concerns in an effective and engaging way and their commitment to advocacy and improvement in the quality of care for patients.

Workings of the human spirit in palliative care situations: a consensus model from the Chaplaincy Research Consortium.

BACKGROUND: Chaplaincy is a relatively new discipline in medicine that provides for care of the human spirit in healthcare contexts for people of all worldviews. Studies indicate wide appreciation for its importance, yet empirical research is limited. Our purpose is to create a model of human spiritual processes and needs in palliative care situations so that researchers can locate their hypotheses in a common model which will evolve with relevant findings. METHODS: The Model Building Subgroup worked with the Chaplaincy Research Consortium as part of a larger Templeton Foundation funded project to enhance research in the area. It met with members for an hour on three successive occasions over three years and exchanged drafts for open comment between meetings. All members of the Subgroup agreed on the final draft. RESULTS: The model uses modestly adapted existing definitions and models. It describes the human experience of spirituality during serious illness in three renditions: visual, mathematical, and verbal so that researchers can use whichever is applicable. The visual rendition has four domains: spiritual, psychological, physical and social with process arrows and permeable boundaries between all areas. The mathematical rendition has the same four factors and is rendered as an integral equation, corresponding to an integrative function postulated for the human spirit. In both renditions, the model is notable in its allowance for direct spiritual experience and a domain or factor in its own right, not only experience that is created through the others. The model does not describe anything beyond the human experience. The verbal rendition builds on existing work to describe the processes of the human spirit, relating it to the four domains or factors. CONCLUSIONS: A consensus model of the human spirit to generate hypotheses and evolve based on data has been delineated. Implications of the model for how the human spirit functions and how the chaplain can care for the patient or family caregiver's spiritual coping and well-being are discussed. The next step is to generate researchable hypotheses, results of research from which will give insight into the human spirit and guidance to chaplains caring for it.

Transcending differences to study the transcendent: an exploratory study of researchers' and chaplains' reflections on interdisciplinary spiritual care research collaboration.

BACKGROUND: Despite recognition of the centrality of professional board-certified chaplains (BCC) in palliative care, the discipline has little research to guide its practices. To help address this limitation, HealthCare Chaplaincy Network funded six proposals in which BCCs worked collaboratively with established researchers. Recognizing the importance of interdisciplinary collaboration in the development of a new field, this paper reports on an exploratory study of project members' reflections over time on the benefits and challenges of conducting inter-disciplinary spiritual care research. METHODS: Data collection occurred in two stages. Stage 1 entailed two independent, self-reflective focus groups, organized by professional discipline, mid-way through the site projects. Stage 2 entailed end-of-project site reports and a conference questionnaire. RESULTS: Eighteen professionals participated in the group discussions. Stage 1: researchers perceived chaplains as eager workers passionately committed to their patients and to research, and identified challenges faced by chaplains in learning to conduct research. Chaplains perceived researchers as passionate about their work, were concerned research might uncover negative findings for their profession, and sensed they used a dissimilar paradigm from their research colleagues regarding the 'ways of relating' to knowledge and understanding. Stage 2: researchers and chaplains noted important changes they ascribed to the interdisciplinary collaboration that were classified into six domains of cultural and philosophical understanding: respect; learning; discovery; creativity; fruitful partnerships; and learning needs. CONCLUSIONS: Chaplains and researchers initially expressed divergent perspectives on the research collaborations. During the projects' lifespans, these differences were acknowledged and addressed. Mutual appreciation for each discipline's strengths and contributions to inter-professional dialogue emerged.

Clinical ethics residency for nurses: an education model to decrease moral distress and strengthen nurse retention in acute care.

The experience of unaddressed moral distress can lead to nurse attrition and/or distancing from patients, compromising patient care. Nurses who are confident in their ethical decision making abilities and moral agency have the antidote to moral distress for themselves and their colleagues and can act as local or institutional ethics resources. We describe a grant-funded model education program designed to increase ethics competence throughout the institution.

Enhancing moral agency: clinical ethics residency for nurses.

One antidote to moral distress is stronger moral agency-that is, an enhanced ability to act to bring about change. The Clinical Ethics Residency for Nurses, an educational program developed and run in two large northeastern academic medical centers with funding from the Health Resources and Services Administration, intended to strengthen nurses' moral agency. Drawing on Improving Competencies in Clinical Ethics Consultation: An Education Guide, by the American Society for Bioethics and Humanities, and on the goals of the nursing profession, CERN sought to change attitudes, increase knowledge, and develop skills to act on one's knowledge. One of the key insights the faculty members brought to the design of this program is that knowledge of clinical ethics is not enough to develop moral agency. In addition to lecture-style classes, CERN employed a variety of methods based in adult learning theory, such as active application of ethics knowledge to patient scenarios in classroom discussion, simulation, and the clinical practicum. Overwhelmingly, the feedback from the participants (sixty-seven over three years of the program) indicated that CERN achieved transformative learning.

Chaplaincy in a Free-Standing Psychiatric Hospital During the COVID-19 Pandemic.

This Special Issue discusses the results of the international COVID-19 survey that took place during the first wave of the pandemic. This contribution discusses chaplaincy in a psychiatric hospital during the COVID-19 pandemic. Chaplaincy vignettes with patients and interventions with staff are described, showing how chaplaincy changed and remained the same during this time. The focus here is on acknowledging disturbed and broken connections, as well as intervening to sustain community.

After the DNR: Surrogates Who Persist in Requesting Cardiopulmonary Resuscitation.

Some health care organizations allow physicians to withhold cardiopulmonary resuscitation from a patient, despite patient or surrogate requests that it be provided, when they believe it will be more harmful than beneficial. Such cases usually involve patients with terminal diagnoses whose medical teams argue that aggressive treatments are medically inappropriate or likely to be harmful. Although there is state-to-state variability and a considerable judicial gray area about the conditions and mechanisms for refusals to perform CPR, medical teams typically follow a set of clearly defined procedures for these decisions. The procedures are based on the principle of nonmaleficence and typically include consultation with hospital ethics committees, reflecting the guidelines of relevant professional associations. Ethical debates about when CPR can and should be limited tend to rely more on discussions of theory, principles, and case studies than systematic empirical study of the situations in which such limitations are applied. Sociologists of bioethics call for empirical study, arguing that what ethicists and health professionals believe they are doing when they draft policies or invoke principles does not always mirror what is happening on the ground. In this article, we begin the task of modeling the empirical analyses sociologists call for, focusing on a cohort at Massachusetts General Hospital. We inductively analyzed ethics committee notes and medical records of nineteen patients whose surrogates did not accept the decision to withhold CPR.

Teaching health care providers to provide spiritual care: a pilot study.

BACKGROUND: Health care providers' lack of education on spiritual care is a significant barrier to the integration of spiritual care into health care services. OBJECTIVE: The study objective was to describe the training program, Clinical Pastoral Education for Healthcare Providers (CPE-HP) and evaluate its impact on providers' spiritual care skills. METHODS: Fifty CPE-HP participants completed self-report surveys at baseline and posttraining measuring frequency of and confidence in providing religious/spiritual (R/S) care. Four domains were assessed: (1) ability and (2) frequency of R/S care provision; (3) comfort using religious language; and (4) confidence in providing R/S care. RESULTS: At baseline, participants rated their ability to provide R/S care and comfort with religious language as "fair." In the previous two weeks, they reported approximately two R/S patient conversations, initiated R/S conversations less than twice, and prayed with patients less than once. Posttraining participants' reported ability to provide spiritual care increased by 33% (p<0.001). Their comfort using religious language improved by 29% (p<0.001), and frequency of R/S care increased 75% (p<0.001). Participants reported having 61% more (p<0.001) R/S conversations and more frequent prayer with patients (95% increase; p<0.001). Confidence in providing spiritual care improved by 36% overall, by 20% (p<0.001) with religiously concordant patients, and by 43% (p<0.001) with religiously discordant patients. CONCLUSIONS: This study suggests that CPE-HP is an effective approach for training health care providers in spiritual care. Dissemination of this training may improve integration of spiritual care into health care, thereby strengthening comprehensive patient-centered care.

Examining Forms of Spiritual Care Provided in the Advanced Cancer Setting.

Spiritual care (SC) is important to the care of seriously ill patients. Few studies have examined types of SC provided and their perceived impact. This study surveyed patients with advanced cancer (N = 75, response rate [RR] = 73%) and oncology nurses and physicians (N = 339, RR = 63%). Frequency and perceived impact of 8 SC types were assessed. Spiritual care is infrequently provided, with encouraging or affirming beliefs the most common type (20%). Spiritual history taking and chaplaincy referrals comprised 10% and 16%, respectively. Most patients viewed each SC type positively, and SC training predicted provision of many SC types. In conclusion, SC is infrequent, and core elements of SC-spiritual history taking and chaplaincy referrals-represent a minority of SC. Spiritual care training predicts provision of SC, indicting its importance to advancing SC in the clinical setting.

Nurse and physician barriers to spiritual care provision at the end of life.

CONTEXT: Spiritual care (SC) from medical practitioners is infrequent at the end of life (EOL) despite national standards. OBJECTIVES: The study aimed to describe nurses' and physicians' desire to provide SC to terminally ill patients and assess 11 potential SC barriers. METHODS: This was a survey-based, multisite study conducted from October 2008 through January 2009. All eligible oncology nurses and physicians at four Boston academic centers were approached for study participation; 339 nurses and physicians participated (response rate=63%). RESULTS: Most nurses and physicians desire to provide SC within the setting of terminal illness (74% vs. 60%, respectively; P=0.002); however, 40% of nurses/physicians provide SC less often than they desire. The most highly endorsed barriers were "lack of private space" for nurses and "lack of time" for physicians, but neither was associated with actual SC provision. Barriers that predicted less frequent SC for all medical professionals included inadequate training (nurses: odds ratio [OR]=0.28, 95% confidence interval [CI]=0.12-0.73, P=0.01; physicians: OR=0.49, 95% CI=0.25-0.95, P=0.04), "not my professional role" (nurses: OR=0.21, 95% CI=0.07-0.61, P=0.004; physicians: OR=0.35, 95% CI=0.17-0.72, P=0.004), and "power inequity with patient" (nurses: OR=0.33, 95% CI=0.12-0.87, P=0.03; physicians: OR=0.41, 95% CI=0.21-0.78, P=0.007). A minority of nurses and physicians (21% and 49%, P=0.003, respectively) did not desire SC training. Those less likely to desire SC training reported lower self-ratings of spirituality (nurses: OR=5.00, 95% CI=1.82-12.50, P=0.002; physicians: OR=3.33, 95% CI=1.82-5.88, P<0.001) and male gender (physicians: OR=3.03, 95% CI=1.67-5.56, P<0.001). CONCLUSION: SC training is suggested to be critical to the provision of SC in accordance with national care quality standards.

Why is spiritual care infrequent at the end of life? Spiritual care perceptions among patients, nurses, and physicians and the role of training.

PURPOSE: To determine factors contributing to the infrequent provision of spiritual care (SC) by nurses and physicians caring for patients at the end of life (EOL). PATIENTS AND METHODS: This is a survey-based, multisite study conducted from March 2006 through January 2009. All eligible patients with advanced cancer receiving palliative radiation therapy and oncology physician and nurses at four Boston academic centers were approached for study participation; 75 patients (response rate = 73%) and 339 nurses and physicians (response rate = 63%) participated. The survey assessed practical and operational dimensions of SC, including eight SC examples. Outcomes assessed five factors hypothesized to contribute to SC infrequency. RESULTS: Most patients with advanced cancer had never received any form of spiritual care from their oncology nurses or physicians (87% and 94%, respectively; P for difference = .043). Majorities of patients indicated that SC is an important component of cancer care from nurses and physicians (86% and 87%, respectively; P = .1). Most nurses and physicians thought that SC should at least occasionally be provided (87% and 80%, respectively; P = .16). Majorities of patients, nurses, and physicians endorsed the appropriateness of eight examples of SC (averages, 78%, 93%, and 87%, respectively; P = .01). In adjusted analyses, the strongest predictor of SC provision by nurses and physicians was reception of SC training (odds ratio [OR] = 11.20, 95% CI, 1.24 to 101; and OR = 7.22, 95% CI, 1.91 to 27.30, respectively). Most nurses and physicians had not received SC training (88% and 86%, respectively; P = .83). CONCLUSION: Patients, nurses, and physicians view SC as an important, appropriate, and beneficial component of EOL care. SC infrequency may be primarily due to lack of training, suggesting that SC training is critical to meeting national EOL care guidelines.

The spiritual and religious identities, beliefs, and practices of academic pediatricians in the United States.

PURPOSE: Physicians' spiritual and religious identities, beliefs, and practices are beginning to be explored. The objective of this study was to gather descriptive information about personal religion and spirituality from a random sample of academic American pediatricians and to compare this information with similar data from the public. METHOD: In 2005, a Web-based survey of a random sample of 208 pediatrician faculty from 13 academic centers ranked by the US News & World Report as "honor roll" hospitals was conducted. Surveys elicited information about personal beliefs and practices as well as their influence on decisions about patient care and clinical practice. Multiple questions were replicated from the General Social Survey to enable comparisons with the public. Descriptive statistics were generated, and logistic regression analyses were conducted on relevant variables. RESULTS: Nearly 88% of respondents were raised in a religious tradition, but just 67.2% claimed current religious identification. More than half (52.6%) reported praying privately; additional spiritual practices reported included relaxation techniques (38.8%), meditation (29.3%), sacred readings (26.7%), and yoga (19%). The majority of academic pediatricians (58.6%) believed that personal spiritual or religious beliefs influenced their interactions with patients/colleagues. These odds increased 5.1-fold when academic pediatricians attended religious services monthly or more (P < .05). CONCLUSIONS: Compared with the American public, a notably smaller proportion of academic pediatricians reported a personal religious identity. The majority believed spiritual and religious beliefs influenced their practice of pediatrics. Whether secular or faith-based belief systems measurably modify academic pediatric practice is unknown.