How rural nurses in Southern New Zealand navigate their ethical landscape-A qualitative study.

OBJECTIVE: To explore rural nurse experiences of ethical issues and their management of these as a first step in a programme of work to address rural nurses' ethical needs. DESIGN: This study was qualitative, using mixed qualitative techniques to gather data, which was analysed using a general inductive approach. SETTING: Primary health care in 2 regions of Aotearoa New Zealand. PARTICIPANTS: Eleven nurses working in the West Coast (District Health Board) region and 9 working within the Southern District Health Board region. INTERVENTION: Participants took part in either a focus groups or an interview with members of the research team. MAIN OUTCOME MEASURES: To document ethical issues that confronted these rural nurses and how they navigated these issues. RESULTS: Three themes were identified: 'Signals and Silences,' 'One and Other' and 'Frustrations and Freedoms.' A continuous thread through these themes was the concept of phronesis, or what is sometimes called practical virtue. This practical virtue largely developed through their own experiences, rather than through educational or health system specific support or resources. CONCLUSIONS: We found that rural nurses' deal with specific issues related to the rural setting, such as resourcing and isolation, while maintaining a relationship with the communities they serve and their professional autonomy. Additionally, we discovered the ways in which rural nurses deal with the ethical issues they encounter to be practically focussed. However, rural nurses need supportive leadership not only to sustain the moral agency they demonstrate but also to further develop their ethical decision-making practices. The provision of a clinical ethics tele-service delivering both training opportunities and an on-call consult support service would provide a potential solution.

The establishment of conscientious monopolies in rural communities.

In the United States, healthcare providers have the federally protected right to conscientiously refuse to provide treatments or services that they feel violate their moral or religious values. This refusal of services is colloquially known as "conscientious objection," which has become a polarizing topic in today's medical and ethical landscape. Typically, physicians exercising their right to conscientious objection do not represent a barrier in access to care for most patient populations. This dynamic shifts, however, in rural America, where there are relatively few providers. In this commentary, we discuss some of the unique ramifications that are likely to occur when rural providers invoke conscientious objection in their medical practice and how this can in turn establish conscientious monopolies for the members of their communities.

Between the idea and the reality: GP liaison in a rural setting.

OBJECTIVES: To describe the organisational, clinical and pragmatic features of a GP liaison service established by the Division of Mental Health in the Darling Downs Hospital and Health Service catchment to facilitate the care of rural patients and improve communication between primary and specialist care. CONCLUSIONS: The GP liaison service was created using funding from the Commonwealth STP initiative to provide weekly registrar clinics to primary care providers in the Darling Downs. The service was eagerly accepted by providers who saw patient benefits outweighing financial considerations. Expectations of a greater level of care than the assessment and advice provided reflects the large unmet need for mental health services in rural areas. GPs expressed enthusiasm for true collaborative care, such as case management overseen by the public mental health service but based at GP offices.

Philosophizing social justice in rural palliative care: Hayek's moral stone?

Increasingly, palliative care is being referred to as an essential programme and in some cases as a human right. Once it is recognized as such, it becomes part of the lexicon of social justice in that it can be argued that all members of society should have access to such care. However, this begs the question of how that care should be enacted, particularly in rural and remote areas. This question illustrates some of Friedrich Hayek's critiques of social justice. Hayek has likened social justice to a 'moral stone' arguing that social justice is meaningless to the extent that society is impersonal and as such cannot be just, only those individuals who make up that society can be just. When responsibility for justice is assigned to an impersonal society, ideas of social justice can become a clarion call for whom no one is directly accountable. This opens the door for questionable macro-level political agendas that have no capacity to enact the ideal, and worse, may suppress individual moral acts towards the desired end. Further, acts of interference at the macro level with the ideal of equal opportunity run the risk of disadvantaging other members of society. Instead, he has argued that a better approach lies in finding ways to induce and support individual moral acts that promote the human good. Hayek's arguments are particularly compelling for rural palliative care. In this paper we draw upon data from an ethnographic study in rural palliative care to illustrate the potential misfit between the ethical ideal of palliative care as expressed by rural participants and the narratives of social justice.

Ethical professional practice: exploring the issues for health services to rural Aboriginal communities.

CONTEXT: This article provides a first person account of the experience of professional ethics for a psychologist who has worked in several Aboriginal communities in Alberta, Canada. ISSUES: These small rural communities tend to have few services and health services are typically provided by multidisciplinary health teams. Team members are predominantly community members, creating an embedded service environment that highlights the need for integrity in relationships. As the psychologist travelling to these communities I require sensitivity to cultural considerations, multiple party responsibilities, and community pressure on service delivery. LESSONS LEARNED: In these settings, in consideration of the principle of respect for the dignity of persons, there is enhanced need for non-discrimination, particularly as most community members are vulnerable persons. Also, the context of small community clinics highlights issues of privacy and confidentiality. Responsible caring in these kinds of general practice also raise ongoing questions about competence and the need for daily risk-benefit analysis. Finally, responsibility to society is also an overarching consideration given the conditions of Canadian Aboriginal communities.

Continuing education training focused on the development of behavioral telehealth competencies in behavioral healthcare providers.

INTRODUCTION: Telehealth allows behavioral health care and specialty services to be extended to rural residents. Telehealth is an important resource for the Alaskan healthcare system, which is tasked with providing services to culturally diverse populations living in remote areas. Training competent providers to deliver telehealth services is vital for the implementation of successful telehealth programs. Yet, the literature is lacking in the area of provider behavioral telehealth competency training. METHODS: This study assessed the impact of a Behavioral Telehealth Ethical Competencies Training program on 16 behavioral health providers' development of behavioral telehealth competency. A total of 14 competencies were developed, which required participants to understand the roles and responsibilities of a behavioral telehealth coordinator working at the distal site as well as the roles and responsibilities of the therapist. Video vignettes evaluating the 14 competencies, self-reported competence surveys and follow-up surveys of progress on telehealth goals were utilized to assess effects of the training. RESULTS: Results indicated participants' behavioral telehealth competencies increased following training. Participants reported positive perceptions regarding their competency, and achieved progress on the majority of behavioral telehealth goals set during the training. CONCLUSIONS: This study provides a baseline for developing a best practice model for behavioral telehealth service delivery by identifying specific provider competencies for administering effective behavioral telehealth services. A unique continuing education training model, led by content experts including university professors and Alaska Native Elders, incorporating behavioral telehealth, rural ethics, cultural competency and vicarious trauma training is described. Lastly, this study details the use of an innovative video vignette assessment instrument for evaluating the effectiveness of continuing education training.

Lungurra Ngoora--a pilot model of care for aged and disabled in a remote Aboriginal community--can it work?

INTRODUCTION: The literature on the health of and services for older Aboriginal and Torres Strait Islander populations is relatively sparse. This study explored the development and implementation of a locally designed community service model of care for older people, and people with disability and/or mental health problems in remote Aboriginal Australia. METHODS: Based on extensive community consultation with older people, families, carers, community members and stakeholders, a model of care was developed to address unmet needs for the target population and their carers in the remote community of Looma, in the Kimberley region of Australia. The model was implemented and evaluated over 12 months. The main outcome measures included the number of services (including home services, meals, transport, respite, personal care and advocacy) provided. Outcomes of community participation, capacity building, resources, partnerships, workforce, service delivery and cultural protection were assessed qualitatively by an external evaluator. RESULTS: The number of people receiving community care services in Looma increased from eight to 22, and services increased in all domains from 140 total services delivered for 1 month at baseline to 2356 by the final month of the program. CONCLUSIONS: The Lungurra Ngoora community care service model pilot project demonstrated a successful collaborative service model that addressed the care needs of older persons, those with disability and mental illness, and their carers in this remote community. The developmental approach, and model structure, could serve as a template for future delivery of services in remote Aboriginal communities.

'Any body is better than nobody?' Ethical questions around recruiting and/or retaining health professionals in rural areas.

INTRODUCTION: The literature on recruiting and/or retaining health professionals in rural areas focuses primarily on the development of recruitment and retention strategies and assessing whether such strategies are effective. The objective of this article is to argue that it is important for all stakeholders involved in rural recruitment and/or retention processes to consider their decisions and actions from an ethics perspective. Recruitment and/or retention processes are not value neutral and it is important to understand their ethical dimensions. METHODS: From the literature, elements of the recruitment and/or retention strategies that have been employed were identified and organised in respect of levels of governance (namely, the levels of health system/government, community, and individual health professionals). The elements identified in these levels were subjected to analysis to identify their ethical dimensions and to determine whether a clash or complement of values arose at each level of governance or between governance levels. RESULTS: There is very little literature in this area that considers the ethical dimensions of rural recruitment and/or retention processes. However, all policies and practices have ethical dimensions that need to be identified and understood as they may have significant implications for recruitment and/or retention processes. CONCLUSIONS: This article recommends the application of an ethics perspective when reflecting on rural recruitment and/or retention strategies. The collective decisions of all involved in rural recruitment and/or retention processes may fundamentally influence the 'health' (broadly understood) of rural communities.

Ethical challenges of practicing in rural areas.

Mental health professionals practicing in rural areas face ethical dilemmas different from those experienced by their urban counterparts and may find that the existing ethics literature and American Psychological Association (APA, 2002) ethics code not particularly helpful. We highlight parts of five standards from the APA ethics code to illustrate the dilemmas rural practitioners frequently confront and offer suggestions for how to handle them. We discuss competence, human relations, and confidentiality as specific areas and then examine assessment and therapy as broader situations in which dilemmas may occur. We use case examples to highlight complications that may arise in rural areas.

Mental health collaborative care: a synopsis of the Rural and Isolated Toolkit.

CONTEXT: For those residing in rural and isolated parts of Canada, obtaining quality mental health services is often an unfulfilled wish. Rural and isolated communities share the problems of health status and access to care. Health deteriorates the greater the distance from urban areas in the following dimensions: lower life expectancy than the national average; higher rates of disability, violence, poisoning, suicide and accidental death; and more mental and physical health issues than those who live in urban areas. The Canadian Collaborative Mental Health Initiative (CCMHI) was formed to provide, in part, a practical means to encouraging collaborations between primary care and mental health providers. ISSUE: This article provides a synopsis of the Rural and Isolated (R&I) toolkit developed through the CCMHI, which was intended to develop primary care and mental health collaboration in such areas. This toolkit was developed using focus group discussions with mental health providers, and surveys completed by providers and consumers. LESSONS LEARNED: Key messages from the consultative process included: access to services; interprofessional education; consumer involvement; research and evaluation; models of collaboration; ethics; funding; and policy and legislation. A flow diagram was devised to detail the synthesis and practical application of the toolkit, as well as the challenges, key questions and principles of implementation associated with collaborative care initiatives in rural and isolated regions.

The provision of neuropsychological services in rural/regional settings: professional and ethical issues.

Despite rapid growth of the discipline of clinical neuropsychology during recent times, there is limited information regarding the identification and management of professional and ethical issues associated with the practice of neuropsychology within rural settings. The aim of this article is to outline the characteristics unique to practicing neuropsychology in rural communities and to describe the potential professional and ethical dilemmas that might arise. Issues are illustrated using examples from neuropsychological practice in a rural/regional setting in Victoria, Australia. Relative to urban regions, there is an inequality in the distribution of psychologists, including neuropsychologists, in rural areas. The unique characteristics of rural and regional communities that impact on neuropsychological practice are: 1) limited resources in expertise, technology, and community services, 2) greater travel distances and costs, 3) professional isolation, and 4) beliefs about psychological services. These characteristics lower the threshold for particular ethical issues. The ethical issues that require anticipation and careful management include: 1) professional competence, 2) multiple relationships, and 3) confidentiality. Through increased awareness and management of rural-specific professional and ethical issues, rural neuropsychologists can experience their work as rewarding and enjoyable. Specific guidelines for identifying, managing, and resolving ethically and professionally challenging situations that may arise during rural practice are provided.

Rural Health Care and an Ethics of Familiarity.

This commentary focuses on the narratives written from a variety of voices describing the unique challenges and rewards faced in rural health care. The authors speak from various areas of the country and from many professions including medicine, nursing, social work, and ethics and reflect the experiences of learners, new graduates, and long-time practitioners. The authors also represent people who were raised in rural environments and those who are from more urban settings. The commentary includes a discussion of some major themes from the rural bioethics literature that are reflected in these very personal narratives. The themes include lack of resources; overlapping relationships; resiliency; the need for partnerships and collaboration; and creativity. The commentary will also explore the dichotomy between learners and experienced practitioners and the possible missing voice of practitioners who could not tolerate the challenges and who left rural practice.

Exploring the Practical Meaning of Clinical Ethics When Providing Healthcare in Rural and Frontier Settings: Appreciating What Matters.

This article provides an opportunity to ponder the ethics of rural healthcare via a rural or frontier lens. The authors juxtapose the insights, offered in the narratives, with the lessons learned from their more than twenty years of empirical bioethics research in rural communities.

When Specialty Care Is Unavailable to Rural Families.

We present the case of a 2-year-old boy with epidermolysis bullosa and supraglottic stenosis whose parents refuse an elective tracheostomy because of the significant care the tracheostomy would require. The patient's family lives in a rural area with few health care resources and his parents are already handling hours of daily skin care for his epidermolysis bullosa. In an attempt to convince the parents to pursue the intervention, the medical team recommends that the family move to an area with additional resources to assist in the child's care. The parents refuse to move, citing the many benefits their home environment provides for their son. The medical team calls an ethics consultation, questioning whether this decision constitutes medical neglect. This case raises important questions about medical decision-making in pediatrics. First, is a parent's refusal of a recommended medical intervention because it would require moving their family to a new environment a reasonable decision? Second, how broadly can parents define their child's best interest? Should only physical interests be included when making medical decisions? Is there a limit to what can be considered a relevant interest? Third, can parents only consider the interests of the individual child, or can they consider the interests of other members of the family? Finally, what is the threshold for overruling a parental decision? Is it whenever the parent's definition of a patient's best interest is different from the medical team's, or do other criteria have to be met?

Equitable Health Care and Low-Density Living in the United States.

In 1818, John Sinclair's advice for health and longevity included temporary retirement to the country. Two centuries later, life in rural America means higher death rates throughout the lifespan. Health care delivery in rural areas is limited by a number of hardships associated with low-density living, including a shortage of providers, limited cultural diversity, and geography. There are both profound challenges and deep rewards associated with providing health care services in rural areas. Barring a major change in the health care financing and delivery systems, solutions for bringing a full range of quality health care and preventive services to rural residents include incentivizing a full range of providers to practice in rural areas; exploiting the delivery infrastructure that has developed in response to the explosive growth in e-commerce; taking advantage of cellular, digital, and satellite technologies; and learning about what motivates providers to choose rural practice settings.

Ultrasound in rural India: a failure of the best intentions.

The Pre-Conception and Pre-Natal Diagnostic Techniques Act was written to prevent societally unacceptable harms including intentional sex selection. The pragmatism required to enforce this law has profound effects on the ability of rural Indians to access diagnostic ultrasonography. In so doing, it may have inadvertently placed a heavier burden on the poorest and worsened health inequity in India, creating serious ethical and justice concerns. It is time to re-examine and update the law such that diagnostic ultrasonography is widely available in even the most peripheral primary health and community health centres. Shorter, more accessible ultrasonography training courses should be offered; collaboration between radiologists and rural practitioners and facilities should be encouraged. Finally, modern ultrasound machines can carefully record all images via a "silent observer" modality. With some modifications to previously used silent observer modalities, this technology allows both greater access and better policing of potential misuse of ultrasound technology.

Ethics and rural healthcare: what really happens? What might help?

Relatively few articles discuss the ethical issues that accompany healthcare in rural areas. This article presents and discusses the key findings obtained from multi-method research studies conducted over a 9-year period of time in a multi-state rural area. It challenges the efficacy of current models for bioethics, shows what kinds of ethical issues develop in rural communities, and offers a framework for envisioning resources and approaches that may be more appropriate.