Teaching and learning in interprofessional ethics education: Tutors' perspectives.

BACKGROUND: Ethical dilemmas that arise in the clinical setting often require the collaboration of multiple disciplines to be resolved. However, medical and nursing curricula do not prioritize communication among disciplines regarding this issue. A common teaching strategy, problem-based learning, could be used to enhance communication among disciplines. Therefore, a university in southern Taiwan developed an interprofessional ethics education program based on problem-based learning strategies. This study described tutors' experience teaching in this program. AIM: To explore the phenomenon of teaching and learning in interprofessional ethics education for medical and nursing students from the perspectives of tutors. DESIGN: Phenomenological qualitative research. METHODS: Medical and nursing students completed a 6-week interprofessional ethics education program moderated by either physician or nurse tutors. At the conclusion of the ethics education program, all 14 tutors were invited to participate in focus group interviews. Among them, six tutors (three nursing tutors and three physician tutors) participated in additional individual interviews. All of the contents from the focus group interviews and individual interviews were recorded and transcribed. Using the phenomenological approach, the phenomenon of teaching and learning in interprofessional ethics education were generated. ETHICAL CONSIDERATION: The study was approved by the Institutional Review Board. FINDINGS: Three themes emerged from the tutors' teaching perspectives, including the instructor's motivation to teach, the use of narrative case scenarios, and the emphasis on improving interprofessional ethics communication. DISCUSSION: Problem-based learning creates an interprofessional communication platform in interprofessional ethics education. The phenomenon of value convergence between tutors and students, between different students' professions, and between different students' professional maturities is observed. CONCLUSION: Problem-based learning is an effective teaching strategy for creating a communication platform for interprofessional ethics education. Ethic curriculum should emphasize motivating instructor, use narrative case scenarios, and focus on interprofessional communication.

[The Elephant in the Room: Integrative Care for Community Hospice Palliative Care in Taiwan: An Example of a Regional Teaching Hospital in Pingtung County].

Taiwan has been an aging society since 2018. As a result, long-term care, end-of-life autonomy, and hospice care have received increasing attention. The government of Taiwan promotes home-based healthcare through the National Health Insurance System to enable the efficient utilization of medical resources and reduce overall medical costs. Taiwan's community hospice and palliative care network is expected to serve as the main care model supplementing partial hospitalization and institutional care. In this article, we review the history of and policies related to hospice and palliative care in Taiwan using a literature review and examining Pingtung County as a case study. The implementation of home-based palliative care is also outlined and policy revisions are proposed. The results are intended to provide a reference for healthcare authorities and medical institutions to promote community hospice and palliative care policies. The integrated care model can enhance the capacity of community-based palliative care, support patients receiving palliative care and their family members and caregivers, and ensure physical and psychological comfort for patients. This model contributes to the realization of older adults' preference for dying at home, which is especially pronounced in cultures where traditional Chinese ideas are deeply rooted.

The journey of embracing life: Mothers' perspectives of living with their children with retinoblastoma.

PURPOSE: This study aimed to explore the experience and views of mothers with children who have been diagnosed with retinoblastoma. DESIGN AND METHODS: A descriptive qualitative study was conducted in the period of 2019-2021. Interviews were conducted with 21 mothers of children diagnosed with retinoblastoma in Indonesia. Data were collected by semi-structured interviews and examined by content analysis. RESULTS: Mothers evolved from a sense of unacceptability to accepting challenges and gaining inner strength. Three themes were identified: 1) physical and psychological suffering, 2) awareness of changes and demands, and 3) keep moving forward. Mothers developed positive adaptive mechanisms for coping with the problems associated with having a child with retinoblastoma. Psychological adjustment and religious beliefs were key elements in their journeys toward embracing life in the moment. CONCLUSION: Findings illuminated psychological adaptation and coping strategies of mothers with seriously ill children and highlighted how difficulties and cultural norms shaped the adaptative process. Religion and health beliefs played varied and important roles in helping mothers to manage their stress and enhance their coping strategies. PRACTICE IMPLICATIONS: Our findings revealed that it is important to routinely assess social support, traditional health beliefs, and spirituality on mothers, facilitate mentoring to help mothers find their inner strengths, and develop intervention programs designed to promote psychological adjustment without delaying treatment.

[Living With Cancer: Clinical Application of Mindfulness on Cancer-Related Fatigue].

Cancer-related fatigue is the most common and longest-lasting symptom of discomfort experienced by cancer patients. Its effects on patients include physical, psychological, emotional, and cognitive stress, which greatly reduce quality of life. The field of mind-body integrated medicine has improved gradually in recent years, with many evidence-based studies supporting the efficacy of mindfulness as a symptom management strategy for cancer-related fatigue. Based on a review of the literature, this paper introduces the definition of cancer-related fatigue and related assessments and treatments, describes the origin of mindfulness and related concepts, and introduces mindfulness-based empirical treatment strategies for cancer-related fatigue, including mindfulness-based stress reduction and mindfulness-based cognitive therapy, and their effects. The findings are intended to provide clinicians with a reference for the future care of patients with cancer-related fatigue.

Illness Experiences of Advanced Cancer Patients in Taiwan.

The illness experiences of advanced cancer patients are discussed in a Taiwanese cultural context, using an interpretive ethnographic approach (interviews and participant observations) emphasizing holism and symbolic interactionism. A total of 23 advanced cancer patients from different counties in Taiwan were recruited over a 42-month period. The researcher followed their progress as they approached death to better understand their terminal cancer experiences. An interpretive analysis guided by Agar's hermeneutic cycle approach revealed five emic dimensions: feeling the oppression of death, fighting alongside family, intensifying bodily healing efforts, settling unfinished business, and ending the struggle to control pain. Implications for caregivers are discussed.

Phronesis of nurses: A response to moral distress.

BACKGROUND: As moral action could help nurses reduce moral distress, it is necessary to carry out qualitative research to present the experiences in which nurses apply moral action. AIM: To describe and analyze the phronesis applied by nurses in the face of moral distress. RESEARCH DESIGN: The research participants were invited to participate in in-depth interviews. The research materials were based on the stories described by the research participants and recorded by means of first-person narrative. Narrative analysis was applied to interpret the nurses' phronesis. PARTICIPANTS: Twenty-seven nurses from Taiwan. ETHICAL CONSIDERATIONS: The Institutional Review Board of the Kaohsiung Medical University Hospital in Taiwan confirmed that this study passed the research ethical review. FINDINGS: According to the narrative analysis results, the phenomenon of moral distress contains difficulty, action, and idea transformation. The difficulty is the source of moral distress, action is the practice of moral courage, and idea transformation is the nurse's emotional movement. Action and idea transformation are collectively called phronesis in this study. DISCUSSION: Moral distress refers to a state of suffering caused by situations in which nurses cannot carry out their ethical intentions. Phronesis is the process through which nurses take actions and relocate the subjects and is an ethical way to find relief from moral distress. Starting with empathy and respectful attitudes arising from self-reflection, nurses may be helped to get relief from the suffering of moral distress. CONCLUSION: Phronesis can help nurses positively face the emotional strain of moral distress. This article puts forward a narrative method to complete the four steps of phronesis: write about the care experience, identify the difficulties in the stories, seek the possibility of action, and form a new care attitude, which could help nurses learn to reduce their moral distress.

Phenomenon of moral distress through the aspect of interpretive interactionism.

BACKGROUND: Most previous studies on moral distress focused on the factors that cause moral distress, paying inadequate attention to the moral conflict of nurses' values, the physician-nurse power hierarchy, and the influence of the culture. RESEARCH OBJECTIVE: To analyze the main causes for moral distress with interpretive interactionism. RESEARCH DESIGN: A qualitative study was adopted. PARTICIPANTS: Through purposeful sampling, 32 nurses from 12 different departments were chosen as the samples. ETHICAL CONSIDERATIONS: Approval from the Institutional Review Board of the Kaohsiung Medical University Hospital. FINDINGS: Moral distress is likely to occur in the following clinical situations: patients have no idea about their diseases; the medical decisions fail to meet the optimum benefit of patients; and patients with terminal cancers are not given a proper death. The reason why nurses become trapped in moral distress is that they fail to achieve moral goodness. Inadequate confidence, the physician-nurse power hierarchy, and the Oriental culture affect nurses' goodness-based intention for patients, which deteriorates moral distress. DISCUSSION: The main cause for moral distress is the moral goodness of nurses. If nurses' goodness-based intention for patients is inconsistent with the moral objective of achieving optimum benefit for patients, it leads to moral distress. Culture is an essential background factor of care for patients. In the Oriental culture, family members influence patients' right to know about their diseases, the choice of treatment, and patients' autonomy of not receiving cardio-pulmonary resuscitation. This results in moral distress in medical care. CONCLUSION: The occurrence of moral distress demonstrates that nurses have moral characteristics such as goodness and caring. It is suggested that appropriate educational strategies can be adopted to weaken the power hierarchy between physicians and nurses and enhance nurses' confidence and cultural sensitivity, so as to reduce the moral distress of nurses.

The meaning of rituals after a stillbirth: A qualitative study of mothers with a stillborn baby.

AIMS AND OBJECTIVES: To explore the meaning of rituals that women and their families perform after a stillbirth. BACKGROUND: A cultural taboo in Taiwan prohibits discussing death; thus, parents of stillborn babies have no established public mourning or burial ceremonies to perform for their stillborn children. Stillbirths are often treated as if they had never happened. DESIGN: Qualitative descriptive study. METHODS: In-depth interviews, which were transcribed and content analysed, were conducted with a purposive sample of 16 women discharged from two teaching hospitals in Taiwan after they had a stillbirth. RESULTS: Families engaged in rituals for two underlying reasons: to benefit the deceased child and the immediate family. The meanings of the rituals for the child are presented through three themes: (i) sending the baby's spirit to a safe place, (ii) protecting it from suffering and (iii) preparing it for a better reincarnation. The meanings of rituals for the families are presented through four themes: (i) releasing parental guilt by doing their best for the deceased child, (ii) cutting bonds with the child, (iii) avoiding additional misfortune should they mishandle the funeral and (iv) praying for a successful subsequent pregnancy. CONCLUSIONS: Death-related rituals are highly culturally diverse. This study fills a gap about Asian cultures. Participating in rituals permits a mother to do something for her deceased child, helps relieve her guilt and lets her cope with the stillbirth. Rituals after a stillbirth can help a woman recover from grieving and allow her to hope for a successful subsequent pregnancy. RELEVANCE TO CLINICAL PRACTICE: Health professionals should discuss with bereaved parents what rituals they would like to perform and then respect their decisions. A continuum of care and support that exists from the prenatal diagnosis through the stillbirth and beyond is recommended for parents and families during this difficult time.

Taboo in the Workplace: A Qualitative Study of Taiwanese Nurses' "Not-Eating Pineapple" in Clinical Practice.

There has been an increased emphasis on nurses' mental health and well-being in the workplace. Psychologists have established a correlative link between individual's beliefs on luck and mental health. The pineapple taboo has been observed among Taiwanese hospital nurses as a prevalent superstitious belief for bringing luck or warding off increased clinical workloads, but how and why the ritual persists in the hospital workplace remains unknown. This article aims to explore the latent meaning of observance of the taboo and how it is related to nurses' clinical practice and possibly affects their mental health at work. A qualitative research was designed in line with the hermeneutic phenomenological method. Through purposive sampling, 18 nurse participants were recruited for in-depth semistructured interviews. Resulting from the ensuing analysis, 3 modalities were identified as constituting the spectrum of observance of the taboo: (a) "strictly not eating pineapple"; (b) "not eating pineapple at work"; and (c) "eating pineapple without admitting to doing so." Each reflects the position of nurses revealed in relation to the pineapple taboo in clinical settings. Based on the subjective narratives of nurses, it may be understood as an active moral attempt at "being right" rather than a passive avoidance of bad luck in the taboo observation. The findings facilitate an appropriate understanding of the embedded meaning of nurses' workplace-related belief and its seminal function of empowerment for nurses in holistic nursing practice.

On My Own: A Qualitative Phenomenological Study of Mothers of Young Children with Autism Spectrum Disorder in Taiwan.

BACKGROUND: There has been a dramatic increase in autism around the world. However, little is known about the impact of the Taiwanese primogeniture system on mothers of children with ASD. Greater knowledge is needed to understand the life experiences of Taiwanese mothers with ASD children when a healthy male descendent is expected. MATERIALS AND METHODS: Research follows the hermeneutic phenomenological approach with in-depth interviews and participant observation (Agar, Speaking of Ethnography. Sage, California, 1986). The researchers collected and analysed stories from seven mothers who are the major caregivers of their school-aged autistic children. RESULTS: The data revealed the following themes that represented the mothers' experiences: taking the blame, my world was turned upside down, a child-centred life and two lives as one. CONCLUSIONS: The findings provide a deeper understanding of common expectations of, and behaviours directed towards, Taiwanese mothers of children with autism. This offers healthcare professionals ways of reconceptualizing therapeutic practice, thus benefitting these mothers.

Experience of pelvic floor muscle exercises among women in Taiwan: a qualitative study of improvement in urinary incontinence and sexuality.

AIMS AND OBJECTIVES: To gain an in-depth understanding of women's experiences of performing pelvic floor muscle exercises for urinary incontinence and the impact on their sexuality. BACKGROUND: Urinary incontinence is not a life-threatening disorder; however, it has been shown to have detrimental effects on quality of life in terms of psychological, social and sexual dysfunction. Pelvic floor muscle exercises is the first recommended strategy for managing mild to moderate urinary incontinence as it is noninvasive and cost effective. Pelvic floor muscle exercises reduce incontinence and strengthen the pelvic floor muscles, which positively affects sexual function in women. Currently, the data are scarce for qualitative literature regarding the subjective experiences of Taiwanese women undergoing pelvic floor muscle exercises and the impact on their urinary incontinence and sexuality. DESIGN: Qualitative exploratory study. METHODS: Semi-structured in depth interviews were undertaken with twelve women who had completed a pelvic floor muscle exercises program in Taiwan. Data were analysed using thematic analysis. RESULTS: Themes were related to Taiwanese women's initial feelings that urinary incontinence was inevitable and the effects on their sexuality. Three core themes were identified: perceptions of inevitability, developing awareness and gaining control and sexual taboo. Through developing awareness and control of their pelvic floor muscles women expressed improvement in urinary incontinence. Sexual enjoyment, body image, self confidence and sexuality were also enhanced. CONCLUSION: Pelvic floor muscle exercises had a positive effect on urinary incontinence and sexuality. The findings demonstrated that sex is a taboo topic for many Taiwanese women. With the sensitive management of pelvic floor muscle exercises programs this issue can be addressed. RELEVANCE TO CLINICAL PRACTICE: This study raises awareness of healthcare professionals by identifying how Taiwanese women perceive pelvic floor muscles. The positive impact of pelvic floor muscle exercises upon both urinary incontinence and sexuality within the Taiwanese context are addressed. Nurses may also, with greater confidence initiate discussion of women's sexual concerns as part of managing urinary incontinence.

[Disorder in life and the world: the illness experiences of women with diabetes in Taiwan].

BACKGROUND: The role of women is strongly associated with health behavior. Understanding the illness experiences of women with diabetes helps health professionals to provide appropriate health care to women with diabetes. PURPOSE: The purpose of this study was to explore the illness experiences of women with diabetes. METHODS: This study used interpretive ethnographic methods with in-depth interviews and field observations to obtain emic points of view from women who were diagnosed with diabetes. Agar's hermeneutic cycle was used to analyze the collected data. The participants were recruited under the principle of maximum variation. The inclusion criteria targeted women who: (1) had been diagnosed with diabetes for at least one year, (2) were able to speak Mandarin or Taiwanese, and (3) were willing to participate and have their sessions tape-recorded in a diabetes clinic in southern Taiwan. A total of 18 women with diabetes between 24 and 79 years of age were enrolled as participants. RESULTS: "Disorder in life and the world" was the main storyline elicited from participants. The four themes con-structed from this disorder were: (1) disorder of the body: reliance on medical care to understand the body, (2) disorder of life: shift from being in control of food to being controlled by food, (3) disorder of the family: sick person is perceived as incompetent, and (4) disorder of the self: controlling the body for the family. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Healthcare providers should recognize and make positive use of the potential of the cultural role of women to improve the ability of women to self-manage their diabetes. Additionally, perceiving the entire family as the client may improve the illness experience for Asian women with diabetes.

[A phenomenological study of the shift change experiences of clinical nurses in Taiwan].

BACKGROUND: The process of changing shifts requires that clinical nurses engage in critical communication and interaction activities. Little research has examined the shift-change phenomenon. How Taiwanese nurses interpret their lived shift-change experiences deserves further exploration. PURPOSE: This study explores the meaning of the shift-change experiences of nurses in Taiwan. METHODS: A hermeneutic phenomenological design was used. Data from interviews, participant observations, and field notes were analyzed. Twenty-six nurses with shift-change experience volunteered in a snowball sampling process. Data were collected using in-depth interviews. Hermeneutical analysis was used to explain the meaning of the nursing shift-change experience. RESULTS: The shift-change experiences of participants revealed their existential meaning and struggles toward self-transformation, adaptation, and self-settlement for survival. The meaning of the shift-change experience of clinical nurses in Taiwan are characterized by three themes: (a) 'A relay for accomplishing collective nursing goals', (b) 'An associated duties to be carried out jointly', and (c) 'An experience transmission as well as power practice'. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: Our study highlights the cultural implications and existential meaning of the clinical shift change experience to nurses in hospitals in Taiwan. These findings provide a better understanding of the nursing shift-change experience in terms of both practical issues and nurses' perceptions. Findings may be used to improve in-service training programs and to suggest solutions to problems encountered during the shift-change period.

The Lived Experiences of Palliative Care Professionals in Cultivating Mindfulness: A Phenomenological Study.

Purpose: The aim of this study was to explore the essence of the lived experiences of palliative care professionals in cultivating mindfulness, with a focus on the meaning of mindfulness in their lives and how mindfulness is experienced throughout their process of caring for others. Design: This was a qualitative study using a phenomenological approach. Methods: Eleven palliative care professionals (three physicians, four nurses, three psychologists, and one spiritual care provider) partook in in-depth interviews. Data were collected from the in-depth interviews and analyzed according to the method of Giorgi. Findings: Two major themes emerged from this study. First, the palliative care professionals realized the need for self-care amid emotional burden, including recognizing their feelings of guilt and self-doubt, emotional contagion of grief, reflections of others' fragility on themself, and their self-imposed limitations. Second, they noticed the transformative impact of mindfulness on them, including detecting reconnection with their body, changes in their personal values, self-acceptance, and liberation. Conclusion: Palliative care professionals can cultivate self-acceptance and facilitate entirely new life experiences through the practice of mindfulness. For them, mindfulness is not merely a self-regulation technique but an existential epiphany, offering hope for self-care and empowerment.

'Struggling to be an insider': a phenomenological design of new nurses' transition.

AIMS AND OBJECTIVES: To obtain a comprehensive understanding of the transition process of new nurses in Taiwan. Background. The transition period for new nurses can be a daunting and traumatic experience. The large number of newly graduated Taiwanese nurses who resign from their jobs within three months indicates that this process can be complicated. However, the problems associated with the experiences of new nurses have not yet been recognised. DESIGN: We adopted a phenomenological design using focus group interviews. METHODS: Sixteen new nurses (less than one year working experience) participated in eight weekly group interviews lasting two hours each to grasp their experience of 'being new'. Interview data were analysed according to Sloan's (2002) three moments, and the whole process of analysis followed the suggestions of Agar (1986), which was performed in a close collaboration between researchers until the consensus about the findings could be reached. RESULTS: The overarching pattern of the transition process of new nurses becoming experienced members of the clinical nursing team was revealed as a journey of 'struggling to be an insider'. This phenomenon was characterised by four themes, including (1) 'being new as being weak', (2) 'masking myself', (3) 'internalising the unreasonable' and (4) 'transforming myself to get a position'. CONCLUSIONS: While Western culture view abusive indoctrination of new nurses as toxic behaviour, under the Chinese traditions of yield, tolerance and self-oppression, following the power hierarchy and seeking harmony, the transition of new nurses is interpreted differently. RELEVANCE TO CLINICAL PRACTICE: Recognition of the journey of 'struggling to be an insider' helps nurse administrators to (1) gain a better understanding of what new nurses encounter in their transition process, (2) help new nurses without harm, (3) improve in-service training programmes and (4) retain future nurses.

Risk and protective factors for suicidal ideation among Taiwanese adolescents.

BACKGROUND: : Suicide is the ninth leading cause of death in adolescents aged 15-19 years in Taiwan. Suicidal ideation is an important predictor of committing suicide among adolescents. OBJECTIVES: : The aim of this study was to examine the important risk factors, the protective factors, and the role of protective factors on the relationship of risk factors to suicidal ideation among Taiwanese adolescents aged 15-19 years. METHODS: : By adopting a cross-sectional study, senior high school students (n = 577) aged 15-19 years in southern Taiwan were recruited for this study. An anonymous self-reported questionnaire was used to collect demographic characteristics, risk factors, protective factors, and suicidal ideation of the sample. Hierarchical logistic regression was used to identify the important risk and protective factors and the interaction between risk and protective factors on suicidal ideation. RESULTS: : Nearly 18% (n = 101) of the participants reported having suicidal ideation during the past 12 months. Gender (female; odds ratio [OR] = 4.23), life stress (OR = 1.03), depression (OR = 3.44), peer suicidal ideation (OR = 4.15), and bullying victimization (OR = 1.81) were important risk factors of suicidal ideation among the targeted sample. In addition, self-esteem (OR = 0.92) and emotional adaptation (OR = 0.88) were important protective factors of suicidal ideation. Self-esteem and emotional adaptation were not used to moderate the negative effects of life stress, depression, perceived peer suicidal ideation, and bullying victimization on suicidal ideation. The final model explained 40.6% of the total variance in suicidal ideation and correctly predicted 86.1% of participants with suicidal ideation. DISCUSSION: : Suicidal ideation prevention programs should be targeted to female adolescents. School-based efforts that provide adolescents with self-esteem enhancement, emotional regulation skills training, positive peer norms for life, coping skills for managing stress and depression, and antibullying programs might help reduce the suicidal ideation of adolescents.

[Racing with illness: the life experiences of mothers of children with duchenne muscular dystrophy].

BACKGROUND: Understanding the life experiences of mothers of children with Duchenne Muscular Dystrophy (DMD) is very important for nurses focused on providing family care. The present study provides valuable insight into this issue, as few studies on this important topic have been done previously. PURPOSE: The objective of this study was to explore thoroughly the life experiences of mothers taking care of DMD children from their own perspectives. METHODS: This study used a phenomenological approach. A purposive sample of 11 mothers of DMD children was recruited from the Taiwan Muscular Dystrophy Association (Southern Chapter). All agreed to join this study and were able to speak either Taiwanese or Mandarin fluently. Data collected through one-to-one, in-depth interviews were analyzed using the Colaizzi (1978) phenomenological methodology. RESULTS: Results showed that the life experiences of mothers of DMD children were typified by the theme, "racing with illness". Four categories emerged from interview data, including: "loss of time and space", "physical and psychological pain", "damage to relationships", and "financial difficulties". CONCLUSIONS: Study findings may help us better understand the life experiences of mothers of children with DMD and may serve as an important reference with regard to how best to coordinate government, medical, education and other support organizations to provide such mothers with greater support and assistance and DMD children with better care.

Uses and Perspectives of Aging Well Terminology in Taiwanese and International Literature: A Systematic Review.

The aim of this study is to examine aging well (AW) terminology in Taiwan in its local and global contexts, and to suggest ways of communication by Taiwanese professionals that is sensitive to the lay public's preferences. Researchers conducted a systematic review using Khan et al.'s strategy, and Harden and Thomas' method, to sift through seven databases and synthesize diverse studies on AW. Primary aging well terms used in English and Chinese, their usage frequency in Taiwanese academia, and one term uniquely used by lay people in Taiwan were identified. The synthesized literature illustrated commonality as well as diversity in use and interpretation of aging well terms within Taiwanese society and compared with the Western-based research. More qualitative research is needed to explore how AW is experienced, interpreted, and expected from lay perspectives in Taiwan and other countries have primarily relied on translation and adaptation of Western terms in their scientific research.

Moral Distress Model Reconstructed Using Grounded Theory.

BACKGROUND: The problems of nurse burnout and manpower shortage relate to moral distress. Thus, having a good understanding of moral distress is critical to developing strategies that effectively improve the clinical ethical climate and improve nursing retention in Taiwan. PURPOSE: The aim of this study was to reconstruct the model of moral distress using the grounded theory. METHODS: Twenty-five staff nurses at work units who attend to the needs of adult, pediatric, acute, and critical disease or end-of-life-care patients were recruited as participants using theoretical sampling from three teaching hospitals in Taiwan. Data were collected using intensive, 2- to 3-hour interviews with each participant. Audio recordings of the interviews were made and then converted into transcripts. The data were analyzed using the grounded theory. RESULTS: In the clinical setting, the perspective that nurses take toward clinical moral events reflects their moral values, which trigger moral cognition, provocation, and appraisal. The moral barriers that form when moral events that occur in clinical settings contradict personal moral values may later develop into moral distress. In handling moral barriers in the clinical environment, nurses make moral judgments and determine what is morally correct. Influenced by moral efficacy, the consequence may either be a moral action or an expression of personal emotion. Wasting National Health Insurance resources and Chinese culture are key sources of moral distress for nurses in Taiwan. The role of self-confidence in promoting moral efficacy and the role of heterodox skills in promoting moral actions represent findings that are unique to this study. CONCLUSIONS: The moral distress model was used in this study to facilitate the development of future nursing theories. On the basis of our findings, we suggested that nursing students be encouraged to use case studies to establish proper moral values, improve moral cognition and judgment capabilities, and promote moral actions to better handle the regular pressures of moral distress in future clinical or workplace settings. Moreover, a better understanding of moral distress may help retain staff nurses.

Factors related to tracheostomy timing and ventilator weaning: findings from a population in Northern Taiwan.

INTRODUCTION: Determining the optimal time for performing a tracheostomy and weaning a patient off a ventilator is typically challenging for physicians, respiratory therapists, patients and patients' families. PURPOSE: This study examined the factors influencing tracheostomy timing and ventilator weaning and described the transition-care placement of patients who experience unsuccessful ventilator weaning. METHODS: A retrospective design was employed, and 2 years of data were collected through a medical chart review performed at a hospital in Northern Taiwan. Sixty patients who received tracheostomies in the intensive care unit (ICU) or respiratory care center were enrolled. The data included each patient's demographic information, disease diagnosis, and Glasgow Coma Scale score and Acute Physiology and Chronic Health Evaluation II scores. RESULTS: For patients on a ventilator in an ICU, the tracheostomy rate was 2.7%. Early (within 21 days) and late (>21 days) tracheostomies accounted for 36.7% and 63.3%, respectively. Of the patients who had received tracheostomies, 36.7% experienced ventilator weaning. The factors related to tracheostomy timing were disease diagnosis (P = 0.036) and days of ventilator use (P = 0.003). The factors related to ventilator weaning included disease diagnosis (P = 0.010) and tracheostomy timing (P = 0.001). Early tracheostomies were 10.9 times more likely than late tracheostomies to result in ventilator weaning (95%CI =2.5-47.7, P = 0.002). CONCLUSIONS: Tracheostomy timing was strongly correlated with ventilator weaning. Early tracheostomy was higher successful ventilator weaning rates. The surgical patients were more likely to receive an early tracheostomy. However, the number of patients in Taiwan who received tracheostomies was lower than that in other countries. Further study maybe need to understand cultural variations in the acceptance of tracheostomies by patients.