What's suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID).

BACKGROUND: Intolerable suffering is a common eligibility requirement for persons requesting assisted death, and although suffering has received philosophic attention for millennia, only recently has it been the focus of empirical inquiry. Robust theoretical knowledge about suffering is critically important as modern healthcare provides persons with different options at end-of-life to relieve suffering. The purpose of this paper is to present findings specific to the understanding and application of suffering in the context of MAID from nurses' perspectives. METHODS: A longitudinal qualitative descriptive study using semi-structured telephone interviews. Inductive analysis was used to construct a thematic account. The study received ethical approval and all participants provided written consent. RESULTS: Fifty nurses and nurse practitioners from across Canada were interviewed. Participants described the suffering of dying and provided insights into the difficulties of treating existential suffering and the iatrogenic suffering patients experienced from long contact with the healthcare system. They shared perceptions of the suffering that leads to a request for MAID that included the unknown of dying, a desire for predictability, and the loss of dignity. Eliciting the suffering story was an essential part of nursing practice. Knowledge of the story allowed participants to find the balance between believing that suffering is whatever the persons says it is, while making sure that the MAID procedure was for the right person, for the right reason, at the right time. Participants perceived that the MAID process itself caused suffering that resulted from the complexity of decision-making, the chances of being deemed ineligible, and the heighted work of the tasks of dying. CONCLUSIONS: Healthcare providers involved in MAID must be critically reflective about the suffering histories they bring to the clinical encounter, particularly iatrogenic suffering. Further, eliciting the suffering stories of persons requesting MAID requires a high degree of skill; those involved in the assessment process must have the time and competency to do this important role well. The nature of suffering that patients and family encounter as they enter the contemplation, assessment, and provision of MAID requires further research to understand it better and develop best practices.

Riding an elephant: A qualitative study of nurses' moral journeys in the context of Medical Assistance in Dying (MAiD).

AIMS AND OBJECTIVES: To describes nurses' moral experiences with Medical Assistance in Dying in the Canadian context. BACKGROUND: Nurses perform important roles in Medical Assistance in Dying in Canada and do so within a unique context in which Medical Assistance in Dying is provided through healthcare services and where accessibility is an important principle. International literature indicates that participating in Medical Assistance in Dying can be deeply impactful for nurses and requires a high degree of moral sense-making. DESIGN: A qualitative interview study guided by Interpretive Description using the COREQ checklist. RESULTS: Fifty-nine nurses from across Canada participated in the study. The decision to participate in Medical Assistance in Dying was influenced by family and community, professional experience and nurses' proximity to the act of Medical Assistance in Dying. Nurses described a range of deep and sometimes conflicting emotional reactions provoked by Medical Assistance in Dying. Nurses used a number of moral waypoints to make sense of their decision including patient choice, control and certainty; an understanding that it was not about the nurse; a commitment to staying with patients through suffering; consideration of moral consistency; issues related to the afterlife; and the peace and gratitude demonstrated by patients and families. DISCUSSION: The depth of nurses' intuitional moral responses and their need to make sense of these responses are consistent with Haidt's theory of moral experience in which individuals use reasoning primarily to explain their moral intuition and in which moral change occurs primarily through compassionate social interaction. Further, work on the moral identity of nursing provides robust explanation of how nurses' moral decisions are contextually and relationally mediated and how they seek to guard patient vulnerability, even at their own emotional cost. CONCLUSION: Medical Assistance in Dying is impactful for nurses, and for some, it requires intensive and ongoing moral sense-making. RELEVANCE TO CLINICAL PRACTICE: There is a need to provide support for nurses' moral deliberation and emotional well-being in the context of Medical Assistance in Dying care.

Nursing and euthanasia: A narrative review of the nursing ethics literature.

BACKGROUND: Medical Assistance in Dying, also known as euthanasia or assisted suicide, is expanding internationally. Canada is the first country to permit Nurse Practitioners to provide euthanasia. These developments highlight the need for nurses to reflect upon the moral and ethical issues that euthanasia presents for nursing practice. PURPOSE: The purpose of this article is to provide a narrative review of the ethical arguments surrounding euthanasia in relationship to nursing practice. METHODS: Systematic search and narrative review. Nine electronic databases were searched using vocabulary developed from a stage 1 search of Medline and CINAHL. Articles that analysed a focused ethical question related to euthanasia in the context of nursing practice were included. Articles were synthesized to provide an overview of the literature of nursing ethics and euthanasia. ETHICAL CONSIDERATIONS: This review was conducted as per established scientific guidelines. We have tried to be fair and respectful to the authors discussed. FINDINGS: Forty-three articles were identified and arranged inductively into four themes: arguments from the nature of nursing; arguments from ethical principles, concepts and theories; arguments for moral consistency; and arguments from the nature of the social good. Key considerations included nursing's moral ontology, the nurse-patient relationship, potential impact on the profession, ethical principles and theories, moral culpability for acts versus omissions, the role of intention and the nature of the society in which euthanasia would be enacted. In many cases, the same assumptions, values, principles and theories were used to argue both for and against euthanasia. DISCUSSION: The review identified a relative paucity of literature in light of the expansion of euthanasia internationally. However, the literature provided a fulsome range of positions for nurses to consider as they reflect on their own participation in euthanasia. Many of the arguments reviewed were not nursing-specific, but rather are relevant across healthcare disciplines. Arguments explicitly grounded within the nature of nursing and nurse-patient relationships warrant further exploration.

A very human being: Sister Marie Simone Roach, 1922-2016.

Sister (Sr.) Marie Simone Roach, of the Sisters of St. Martha of Antigonish, Nova Scotia, died at the Motherhouse on 2 July 2016 at the age of 93, leaving behind a rich legacy of theoretical and practical work in the areas of care, caring and nursing ethics. She was a humble soul whose deep and scholarly thinking thrust her onto the global nursing stage where she will forever be tied to a central concept in nursing, caring, through her Six Cs of Caring model. In Canada, she was the lead architect of the Canadian Nurses Association's first code of ethics, and her influence on revisions to it is still profound more than 35 years later. In this paper, four global scholars in nursing and ethics are invited to reflect on Sr. Simone's contribution to nursing and health-care, and we link her work to nursing and health-care going forward.

Searching for ethical leadership in nursing.

BACKGROUND: Attention to ethical leadership in nursing has diminished over the past several decades. OBJECTIVES: The aim of our study was to investigate how frontline nurses and formal nurse leaders envision ethical nursing leadership. RESEARCH DESIGN: Meta-ethnography was used to guide our analysis and synthesis of four studies that explored the notion of ethical nursing leadership. PARTICIPANTS AND RESEARCH CONTEXT: These four original studies were conducted from 1999-2008 in Canada with 601 participants. ETHICAL CONSIDERATIONS: Ethical approval from the original studies covered future analysis. FINDINGS: Using the analytic strategy of lines-of-argument, we found that 1) ethical nursing leadership must be responsive to practitioners and to the contextual system in which they and formal nurse leaders work, and 2) ethical nursing leadership requires receiving and providing support to increase the capacity to practice and discuss ethics in the day-to-day. DISCUSSION AND CONCLUSION: Formal nurse leaders play a critical, yet often neglected role, in providing ethical leadership and supporting ethical nursing practice at the point of patient care.

Examining markers of safety in homecare using the international classification for patient safety.

BACKGROUND: Homecare is a growth enterprise. The nature of the care provided in the home is growing in complexity. This growth has necessitated both examination and generation of evidence around patient safety in homecare. The purpose of this paper is to examine the findings of a recent scoping review of the homecare literature 2004-2011 using the World Health Organization International Classification for Patient Safety (ICPS), which was developed for use across all care settings, and discuss the utility of the ICPS in the home setting. The scoping review focused on Chronic Obstructive Pulmonary Disease (COPD), and Congestive Heart Failure (CHF); two chronic illnesses commonly managed at home and that represent frequent hospital readmissions. The scoping review identified seven safety markers for homecare: Medication mania; Home alone; A fixed agenda in a foreign language; Strangers in the home; The butcher, the baker, the candlestick maker; Out of pocket: the cost of caring at home; and My health for yours: declining caregiver health. METHODS: The safety markers from the scoping review were mapped to the 10 ICPS high-level classes that comprise 48 concepts and address the continuum of health care: Incident Type, Patient Outcomes, Patient Characteristics, Incident Characteristics, Contributing Factors/Hazards, Organizational Outcomes, Detection, Mitigating Factors, Ameliorating Actions, and Actions Taken to Reduce Risk. RESULTS: Safety markers identified in the scoping review of the homecare literature mapped to three of the ten ICPS classes: Incident Characteristics, Contributing Factors, and Patient Outcomes. CONCLUSION: The ICPS does have applicability to the homecare setting, however there were aspects of safety that were overlooked. A notable example is that the health of the caregiver is inextricably linked to the wellbeing of the patient within the homecare setting. The current concepts within the ICPS classes do not capture this, nor do they capture how care responsibilities are shared among patients, caregivers, and providers.

Take me to my leader: the importance of ethical leadership among formal nurse leaders.

Although ethical leadership by formal nurse leaders is critical to enhancing ethical health-care practice, research has shown that many nurses feel unsupported by their leaders. In this article, we consider the limited attention directed toward ethical leadership of formal nurse leaders and how our own research on ethical nurse leadership compares to other research in this field. In searching Nursing Ethics since its inception 20 years ago, we found only a dozen articles that directly addressed this topic. We then reviewed nurses' professional codes of ethics in Canada and found significant retractions of ethical guidelines for formal nurse leaders' ethical responsibilities over the past decade. We began to seek explanations of why this is so and offer some recommendations for the study and enhancement of ethics for formal nurse leadership.

Moral distress: tensions as springboards for action.

In the previous four papers in this series, individual versus structural or contextual factors have informed various understandings of moral distress. In this final paper, we summarize some of the key tensions raised in previous papers and use these tensions as springboards to identify directions for action among practitioners, educators, researchers, policymakers and others. In particular, we recognize the need to more explicitly politicize the concept of moral distress in order to understand how such distress arises from competing values within power dynamics across multiple interrelated contexts from interpersonal to international. We propose that the same socio-political values that tend to individualize and blame people for poor health without regard for social conditions in which health inequities proliferate, hold responsible, individualize and even blame health care providers for the problem of moral distress. Grounded in a critical theoretical perspective of context, definitions of moral distress are re-examined and refined. Finally, recommendations for action that emerge from a re-conceptualized understanding of moral distress are provided.

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.

Letters to the Editor.

This article contains Letters from the Readears.

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.

Ethical nursing practice: inquiry-in-action.

Although the need to theorize ethics within the complexities of nursing practice has been identified within the nursing literature, to date the link between ethics epistemology and specific nursing actions has received limited attention. In particular, little exploration has been carried out to examine how nurses 'know' what is ethical and the knowledge they draw upon to inform their nursing actions within the complexities of their everyday practice. This study describes a participatory inquiry project that focused on developing and articulating an epistemology of ethics while in the midst of everyday nursing work. Epistemological and methodological insights are discussed in light of the challenges nurses face in contemporary healthcare contexts.

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.

Guidance for Ethical Leadership in Nursing Codes of Ethics: An Integrative Review.

There has been limited attention to ethical leadership for formal nurse leaders around the world. Assuming that codes of ethics provide meaningful standards of what is expected of health professionals, what specific guidance for ethical leadership is available to formal nurse leaders in national nursing codes of ethics? We conducted an integrative review of national nursing codes of ethics for 131 member countries of the International Council of Nurses (ICN). In the ICN Code, nurse managers/leaders are highlighted for their role in ethical practice. With the exception of the US, no other country code focuses as much attention on formal nurse leaders. While all country codes (except the United States) implicitly group nurses, practitioners and managers together, most codes do not provide meaningful guidance for formal nurse leaders. The level of ethical guidance provided to formal nurse leaders in national nursing codes of ethics is lacking. However, creating a separate code of ethics for formal nurse leaders is not the answer. Rather, including specific guidance in nursing codes of ethics not only informs nurses about what they can expect of nurse leaders but also allows formal nurse leaders to use the code with their own senior leaders, conveying what their professional body expects of them.

Toward a safer moral climate.

The authors define moral climate in the context of health care as the implicit and explicit values that drive health-care delivery and shape the workplaces in which care is delivered. Over the past six years, their research has focused on describing the moral climates of nurses' workplaces and improving them. In this article, the authors argue that nurses in direct care delivery roles have the insights, expertise and interpersonal skills required to create a much safer moral climate for practice. To make this happen, nurses require opportunities for self-reflection and for true collaboration with their colleagues in management and administration and other health-care disciplines.