Structurational divergence theory as explanation for troublesome outcomes in nursing communication.

Structurational divergence (SD) theory captures negative communication cycles resulting from interpenetration of incompatible meaning structures. It is estimated that 12-15% of practicing nurses suffer from a problematic level of SD. With a sample of 713 nurses (57 departments) in a large hospital, this study tests a model positing SD as a root explanation of nursing job satisfaction and turnover. A number of variables long presumed to be explanations for job satisfaction and turnover were hypothesized as mediators between SD and those outcomes. Path analysis showed support for burnout, role conflict, bullying, and organizational identification as useful mediators, explaining 68% of the variance in job satisfaction, and 45% in intentions to leave. The study also explores relationships between SD and hospital quality indicators. SD is a concern because it powerfully explains a number of poor outcomes and provides an underlying explanation for a number of factors that predict job satisfaction and turnover.

Communication that builds teams: assessing a nursing conflict intervention.

Quality communication is essential for building strong nursing teams. Structurational divergence (SD) theory explains how institutional factors can result in poor communication and conflict cycles; the theory has been developed in nursing context, although it is applicable to all organizational settings. We describe the design, implementation, and evaluation of an intervention to reduce SD and improve nurses' work life and team-member relationships. An intensive 9-hour course provided training in conflict/SD analysis and dialogic conflict/SD management to 36 working nurses from a variety of settings. Quantitative pre- and posttests were administered, with a comparison sample. The course reduced measures of negative conflict attitudes and behaviors: direct personalization, persecution feelings, negative relational effects, ambiguity intolerance, and triangulation (gossiping and complaining to uninvolved third parties). The course also increased important attitudes necessary for productive dialogue and conflict management: perceptions of positive relational effects, conflict liking, and positive beliefs about arguing. As compared with nonparticipants, participant posttests showed lower conflict persecution; higher recognition of positive relational effects; lower perceptions of negative relational effects; higher conflict liking; lower ambiguity intolerance; and lower tendency to triangulate. Qualitatively, participants perceived better understanding of, and felt more empowered to manage, workplace conflicts and to sustain healthier workplace relationships. This intervention can help nurses develop tools to improve system-level function and build productive team relationships.

The Ethics of Conscientious Objection to Teaching Physician-Assisted Death.

The literature on the ethics of conscientious objection focuses on objections to participating in morally contested practices. This literature emphasizes the potential for participation to undermine objecting clinicians' moral integrity. Significantly less attention has been given to conscientious objection to teaching morally contested practices. Thus, it is unclear whether teaching morally contested practices has the potential to undermine objecting educators' moral integrity, and to the extent that it does, what steps can be taken to address this concern. We accordingly examine the ethics of conscientious objection to teaching morally contested practices, with a focus on teaching physician-assisted death (PAD) to trainees in US palliative care programs. We focus on three primary components of teaching PAD: (1) teaching the history and context of PAD; (2) teaching trainees how to understand and respond to requests for PAD; and (3) teaching trainees how to provide PAD. We argue that teaching components one and two has little potential to undermine objecting educators' moral integrity. Moreover, permitting objecting educators to opt out of teaching components one and two might undermine the education of trainees. In contrast, allowing objecting educators to opt out of teaching how to provide PAD may be important to preserving their moral integrity, and is unlikely to undermine trainees' education. We argue that educators should be permitted to opt out of teaching trainees how to provide PAD and describe policies that training programs can adopt to implement this approach.

Palliative care for the terminally ill in America: the consideration of QALYs, costs, and ethical issues.

The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it fares poorly under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially.

Nursing and conflict communication: avoidance as preferred strategy.

An exploratory study was conducted to examine nurses' (n = 57) selection of strategies to confront conflict in the workplace. Communication competence is the conceptual framework, defining competent conflict communication as joint problem-solving communication that is both effective and appropriate. Items were drawn from tools assessing nurses' conflict management strategies. Nurses reported a strong preference not to confront conflict directly; nurse managers were less likely to avoid direct communication. Nurses who do choose to confront conflict are more likely to use constructive than destructive strategies. The integration of the social science of health communication into nursing education and practice and other implications are discussed.

Advanced care decision making: asking the right people the right questions.

Aging often includes chronic disability and/or acute periods of illness. When seriously ill, people may be less able to participate in decision making. Decision making capacity, the ability to give informed consent or informed refusal, may not be accurately assessed or may not be assessed at all. Nurses are often ideally positioned to contribute to decision making by the clinical team and with the patient. Understanding how to assess capacity, and when and how to integrate surrogates into clinical decision making, can contribute to improved patient care. An example is used to explore the process of decision making based on medical indications, patient preferences, and the appropriate roles and responsibilities of the health care team and a surrogate decision maker.

Palliative care for people with Alzheimer's disease.

The task of aligning the philosophical and clinical perspectives on ethics is a challenging one. Clinical practice informs philosophy, not merely by supplying cases, but through shaping and testing philosophical concepts in the reality of the clinical world. In this paper we explore several aspects of the relationship between the philosophical and the clinical within a framework of palliative care for people living with Alzheimer's disease. We suggest that health professionals have a moral obligation to question previous assumptions concerning the quality of life among people with Alzheimer's, and to address the question: does the concept of palliative care properly embrace people with severe dementia? We propose an ethic of palliative care for people with Alzheimer's that is based, not on the traditionally understood principle of autonomy, but on the need to listen to those living with the disease, acknowledging their profound loss of cognitive abilities, with a focus on preventing and relieving suffering, and improving the individual's quality of life.

Applying a Balm: Medicating the Patient to Treat the (Moral) Distress of Caregivers.

Moral distress occurs when a nurse knows the right action but is impeded from taking that right action because of institutional constraints. Caring for patients who are dying might evoke distress, including moral distress. The distress from a difficult clinical situation is likely to permeate other areas of practice. In this article, 2 cases are used as a means to distinguish moral distress from other distress arising from clinical situations. Opportunities to alleviate distress include increasing knowledge, improved communication, enhanced collaboration, and development of institutional supports.

An Assessment of Hospital-Based Palliative Care in Maryland: Infrastructure, Barriers, and Opportunities.

CONTEXT: Maryland recently passed legislation mandating that hospitals with more than 50 beds have palliative care (PC) programs. Although the state's health agency can play a key role in ensuring successful implementation of this measure, there is little actionable information from which it can guide resource allocation for enhancing PC delivery statewide. OBJECTIVES: To assess the PC infrastructure at Maryland's 46 community-based nonspecialty hospitals and to describe providers' perspectives on barriers to PC and supports that could enhance PC delivery. METHODS: Data on PC programs were collected using two mechanisms. First, a survey was sent to all 46 community-based hospital chief executive officers by the Maryland Cancer Collaborative. The Maryland Health Care Commission provided supplementary survey and semistructured interview data. RESULTS: Twenty-eight hospitals (60.9%) provided information on their PC services. Eighty-nine percent of these hospitals reported the presence of a structured PC program. The profile of services provided by PC programs was largely conserved across hospital geography and size. The most common barriers reported to PC delivery were lack of knowledge among patients and/or families and lack of physician buy-in; most hospitals reported that networks and/or conferences to promote best practice sharing in PC would be useful supports. CONCLUSION: Systematic collection of state-level PC infrastructure data can be used to guide state health agencies' understanding of extant resources and challenges, using those data to determine resource allocation to promote the timely receipt of PC for patients and families.

An advance directive in two questions.

It has been two decades since advance directives have become an integral part of health care. Impediments to their optimal usage are common and multifactorial. Decisions commonly have to be made when patients are unable to do so or choose not to participate in decision making, often at the end of life. The use of two questions, 1) "If you cannot, or choose not to participate in health care decisions, with whom should we speak?" and 2) "If you cannot, or choose not to participate in decision making, what should we consider when making decisions about your care?," may accomplish the major goals of an advance directive.

Clinical decision making in palliative care and end of life care.

Clinical decision making involves a consideration of multiple factors; clinical options are constructed based on the objective clinical data and evidence-based standards. Technologic advances have led not only to life saving interventions, but also to the use of these technologies when benefit to the patient was unclear or unexamined. The cases of Karen Quinlan, Nancy Cruzan, and Terri Schiavo provide a framework for examining the evolution of clinical decision making, including when to use or not to use technologies such as ventilators and artificial nutrition and hydration, and the role of specific questions in the process. Advance directives are a means to convey patient preferences, however, in the absence of advance directives, skilled questioning can elicit patient preferences. Nurses' roles in clinical decision making are often nebulous but can be enhanced by understanding these interrelated processes, as well as by knowing the policies and procedures of their institutions.

Oncology nurses' personal understandings about palliative care.

PURPOSE/OBJECTIVES: To examine how oncology nurses define palliative care, views about who should and should not receive palliative care, and beliefs about palliative care decision making, including who should be involved and how decisions should be managed. DESIGN: Qualitative interviews and analysis. SETTING: Preferred location of each respondent. SAMPLE: 12 nurses representing different aspects of oncology nursing. METHODS: An interview guide was employed to ensure that specific topics were covered. Interviews were transcribed verbatim. Qualitative analysis consisted of independent, multiple reviews of the transcripts to share initial findings and identify, refine, and reach consensus on major themes and subthemes. MAIN RESEARCH VARIABLES: Nurses' definitions of palliative care, views about who should and should not receive palliative care, and beliefs about palliative care decision making. FINDINGS: Nurses' perceptions of palliative care focused on symptom management. Most did not distinguish between palliative care and hospice and believed that only patients who were near the end of life should receive palliative care. They viewed their role in decisions regarding palliative care to be limited and indirect. CONCLUSIONS: Although oncology nurses should be at the cutting edge with regard to palliative care, these nurses' personal understandings could serve to limit care for many patients with cancer who could benefit from it. IMPLICATIONS FOR NURSING: Education and clinical experience embedded in a continuous quality-improvement model are needed to ensure sustained change that will overcome the multiple, interwoven barriers to providing appropriate palliative care.

Funeral directors and bereaved children: beliefs and experiences.

As one component of an ongoing project to develop resources for bereaved children and families, funeral directors were surveyed about their experiences and practices with bereaved children. About one-third of respondents reported that they provided services specifically for bereaved children. Of these, some were proactive (reaching out to provide services) whereas others were reactive (responding only when information or services were requested). Many of the participant funeral directors found that families mediated children's involvement or experiences. Often, the parents were perceived as an impediment to optimal experiences for the child. Many funeral directors who did not provide services described being encumbered by a lack of resources, or they perceived that other individuals or organizations in the community were filling that need.