Getting Ours? "Girlbossing" and the Ethics of Nurse Reimbursement Models.

Introduction: This article politicizes a reimbursement model proposed by some professional nursing associations that aim to better align the price of nursing labor (nurses' pay) to the value of nursing and make nurses' contributions more visible. Methods: Using the concept of "missing care," the critique reveals how professionalization directs attention to individual-level interactions between care seekers and practitioners while obscuring from view the harm inflicted by social institutions and structures constitutive of a capitalist political economy and the related carceral state. Results: Direct reimbursement models render practitioners complicit in the harms perpetrated and perpetuated by the health care industrial complex while professionalization processes are deployed to reduce cognitive dissonance (and moral injury) produced by combining harm with nursing's normative principles. Discussion: We describe and trace the complementary capitalist imperatives of extraction-based profit maximization and efficiency through the health care industrial complex to demonstrate how formative those imperatives are of the health care system, care-seekers' outcomes, nurses' experiences, nonconsensual modes of data collection, and surveillance. Conclusion: The naturalization of racial capitalism and the precarity and violence it entails foreclose the creation of ethical alternatives that prioritize well-being instead of the pursuit of profit that could bring the provision of and payment for care closer to the normative principles held by practitioners.

"We Come From Different Worlds": The Collision of Caring and Carceral Institutions.

The purpose of this study was to give voice to the lived experiences of nurses and law enforcement officers whose professional responsibilities converge in the acute care setting, while gaining insight into the perspectives and interpretations of their experiences. Using interpretative phenomenological analysis, this quality study contributes to a growing body of literature exploring the influence of law enforcement in the hospital. Overwhelmingly, participants in this study expressed a contentious dynamic, fueled by arguments, struggles for power, and a feeling of coming from "different worlds." The influence of socially and spatially constructed territories was critical points of contention.

The Toxic Stress of Racism and Its Relationship to Frailty.

Significant morbidity and mortality from COVID-19-related illnesses have been observed among people of color within the United States. While theories involving healthcare inequity and political division have emerged to explain this observation, the role of chronic stress and inflammation is also being explored. Toxic stress is experienced disproportionately by race, ethnicity, and socioeconomic status and increases frailty and vulnerability to diseases such as COVID-19. C-reactive protein (CRP) is a biomarker associated with the inflammatory response that is typically elevated due to exposure to acute or chronic traumatic stress, as well as COVID-19. This study explored the relationship between CRP and Hispanic/non-Hispanic ethnicity among adults hospitalized with COVID-19 via a secondary analysis of retrospective electronic health record (EHR) data collected from a community healthcare system in Southern California. A total of 1,744 cases representing hospitalized adults with COVID-19 were reviewed. Data were extracted from the EHR to reflect demographics, medical diagnoses, medications, CRP, and comorbidity burden. Frequencies, percentages, and measures of central tendency were assessed to understand the distribution of data. Associations were conducted using Pearson's r and the chi-square test of independence. Differences between groups were examined via independent samples t-tests. The sample was 52% Hispanic, 56% male, and the mean age was 62 years (SD = 16.1). The mean age of Hispanic cases was younger than non-Hispanic cases (p < .001, η = 0.289). Serum CRP was significantly higher in the Hispanic cases, with a high degree of association (p < .001, η = 0.472). In addition, higher CRP levels were significantly associated with the need for mechanical ventilation (p < .001, φc = 0.216). No significant relationships were found between CRP and age, body mass index (BMI), or comorbidity burden. Findings challenge the assumption that the disproportionate morbidity and mortality suffered by the Hispanic population due to COVID-19 was due to age, BMI, or comorbidities such as metabolic syndrome or heart disease. CRP in the Hispanic population should be further investigated to understand its relationship to chronic stress, frailty, and risk for COVID-19 in this population.

Nursing as total institution.

Healthcare under the auspices of late-stage capitalism is a total institution that mortifies nurses and patients alike, demanding conformity, obedience, perfection. This capture, which resembles Deleuze's enclosure, entangles nurses in carceral systems and gives way to a postenclosure society, an institution without walls. These societies of control constitute another sort of total institution, more covert and insidious for their invisibility (Deleuze, 1992). While Delezue (1992) named physical technologies like electronic identification badges as key to understanding these societies of control, the political economy of late-stage capitalism functions as a total institution with no cohesive, centralized, connected material apparatus required. In this manuscript, we outline the ways in which the healthcare industrial complex demands nurse conformity and how that, in turn, operationalizes nurses in service to the institution. This foundation leads to the assertion that nursing must foster a radical imagination for itself, unbound by reality as it presently exists, in order that we might conjure more just, equitable futures for caregivers and care receivers alike. To tease out what a radical imagination might look like, we dwell in paradox: getting folks the care they need in capitalist healthcare systems; engaging nursing's deep history to inspire alternative understandings for the future of the discipline; and how nursing might divest from extractive institutional structures. This paper is a jumping-off place to interrogate the ways institutions telescope and where nursing fits into the arrangement.

"So There. I Won.": The Struggle for Power Between Caring and Carceral Institutions.

OBJECTIVE: The objectives of this study were to give voice to the lived experiences of nurses and law enforcement officers (LEOs) who interact with one another in acute hospital settings and to interpret and understand their unique perspectives and experiences. METHODS: This qualitative study employed interpretative phenomenological analysis in the interviews of registered nurses and LEOs. The analysis and discussion was underpinned by biopolitical theories of power and control, including Georgio Agamben, Michel Foucault, and Erving Goffman. RESULTS: There is a paucity of literature on nurse and law enforcement interactions in the hospital setting. Nurses and law enforcement exerted power and authority through several means. Overwhelmingly, participants described a contentious dynamic between nurses and LEOs in the hospital, wrought with argument, stress, and a feeling of coming from "different worlds." CONCLUSION: The results provide alarming examples of deformed caring practices and assert the necessity for continued unearthing and discussion of how nurses can, and should, navigate law enforcement interaction. The tangible interference of care is of particular importance and consideration for nurses. Inequity in care and unfavorable outcomes for already marginalized and vulnerable populations are of grave concern. Additional research is needed on the specific ways this struggle for power between institutions and their political actors impairs caring practices and the emotional and psychological sequelae of these interactions.

Clinical metabolic monitoring to inform metabolic dysregulation in sepsis.

OBJECTIVE: The objective of this study was to offer further evidence of the utility of metabolic monitoring in early recognition of sepsis. Metabolic derangement in sepsis is of increasing interest. Sepsis was redefined as a dysregulated host response to infection, and studies have since emerged advising that disrupted metabolic pathways in sepsis may interfere with the host's ability to convert oxygen to useable energy. Indirect calorimetry (IC) is a metabolic monitoring technology that measures oxygen consumption (V02) and resting energy expenditure (REE). IC offers clinically important, specific information in terms of patient's metabolic state and has been shown to differentiate patients with sepsis from those without. Additionally, IC is more specific than predictive equations used as the established standard for clinical nutrition. RESEARCH METHODS AND PROCEDURES: Data for this retrospective descriptive study were obtained from chart review of records of critically ill patients who received metabolic monitoring while under the care of the nutrition support team. Data were retrieved from January through March of 2020. The cases included were from January 2018 through January 2020. Variables included key demographics, sepsis diagnosis and specific metabolic variables of cellular respiration and energy expenditure. RESULTS: For this all-male sample (N = 56), mean age was 56 years (±17.5). Significant differences were noted in V02 between the two groups of cases (sepsis and non-sepsis); (p = .026, Cohen's d = 0.618); and REE (p = .032, Cohen's d = 0.607). A strong association was found between V02 and sepsis (Eta 0.981). REE as measured by IC was statistically more specific than predictive equation (p < .001, Cohen's d = 0.527). CONCLUSIONS: VO2 and REE were significantly altered in subjects with sepsis in this study, demonstrating that IC may be a useful tool in identifying sepsis. This study was based on an earlier pilot which yielded similar results. Indirect calorimetry can be easily performed clinically, offering specific metabolic information that can be helpful in the determination of a diagnosis of sepsis. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution to this manuscript. The study design, analysis of retrospective data, and manuscript preparation were completed entirely by the authors. IMPLICATIONS FOR CLINICIANS: Sepsis remains one of the number one killers of hospitalized patients globally Current means of identifying sepsis remain overly sensitive and under-specific, making recognition of sepsis challenging for Emergency Clinicians Metabolic monitoring can be done easily in the clinical setting by nurses and respiratory therapists. Metabolic monitoring has the capability of offering further information specific to the identification of sepsis, and to further understanding of the altered metabolic phenotype of patients with sepsis.

Nursing in deathworlds: Necropolitics of the life, dying and death of an unhoused person in the United States healthcare industrial complex.

This paper begins with the lived accounts of emergency and critical care medical interventions in which an unhoused person is brought to the emergency department in cardiac arrest. The case is a dramatised representation of the extent to which biopolitical forces via reduction to bare life through biopolitical and necropolitical operations are prominent influences in nursing and medical care. This paper draws on the scholarship of Michel Foucault, Giorgio Agamben, and Achille Mbembe to offer a theoretical analysis of the power dynamics that influence the health care and death care of patients who are caught in the auspices of a neoliberal capitalist healthcare apparatus. This paper offers analysis of the overt displays of biopower over those individuals cast aside as generally unworthy of access to healthcare in a postcolonial capitalist system, in addition to the ways in which humans are reduced to 'bare life' in their dying days. We analyse this case study through Agamben's description of thanatopolitics, a 'regime of death', and the technologies that accompany the dying process, particularly in that of the homo sacer. Additionally, this paper illustrates the ways in which necropolitics and biopower are integral to understanding how the most advanced and expensive medical interventions make visible the political values of the healthcare system and how nurses and healthcare functions in these deathworlds. The purpose of this paper is to develop a greater understanding of biopolitical and necropolitical operations in acute and critical care environments, and to offer guidance to nurses in these spaces as they work to uphold ethical duties in a system that increasingly dehumanises.

Nurses as Disciplinary Agents of the State: Ethical Practice and Mandatory Reporting in the United States.

This article reviews legislative initiatives that mandate nurses to report patients, families, and clinicians to law enforcement. Most recently, these laws target transgender and gender diverse (TGD) youth and people seeking abortion. In this article, we examine the ethics of such laws through professional ethical codes. Furthermore, through a biopolitical lens, we critically analyze examples of nurses' participation in complying with laws that harm patients. Finally, we discuss the damage these laws have on the nursing profession and assert the necessity of a resituating of professional ethics that considers the complexity of nursing care amidst increasingly blatant state-sanctioned violence.

A mixed methods study of moral distress among frontline nurses during the COVID-19 pandemic.

OBJECTIVE: The study's purpose was to develop an understanding of factors affecting moral distress among nurses during the COVID-19 pandemic. METHOD: California-licensed, registered nurses who cared for COVID-19 patients for at least 3 months were recruited for an explanatory concurrent mixed methods study. Data are derived from the first of two surveys administered 3 months apart, including open-ended questions. RESULTS: Variables with significant bivariate correlations were included as simultaneous predictors in a linear regression model predicting moral distress. The overall model was significant, explaining a substantial portion of the variance in moral distress, but results showed only organizational support and institutional betrayal uniquely predicted moral distress. Three qualitative themes were identified: Ethical Violations in Care, Institutional Betrayal, and Traumatic Strain. The impacts of organizational support and institutional betrayal on nurses' moral distress are important findings in both datasets. CONCLUSIONS: Findings provide insights into how nurses' experiences affected their feelings about work. Participants indicated feeling disregarded by management and institutional structures, indicating potential means of slowing the rates at which nurses plan to leave bedside practice. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Gender Influences in the Intersection of Acute Care Registered Nurses and Law Enforcement: The Collision of Caring and Carceral Institutions.

To give voice to the lived experiences of nurses and law enforcement officers who interact with one another in an acute care hospital setting, while gaining an understanding of individual perspectives and unique experiences, as well as how they interpret these experiences. This qualitative study used interpretative phenomenological analysis (IPA) to strive to meet the study objectives. There is a paucity of literature on the topic of nurse and law enforcement interaction in the hospital setting. Overwhelmingly, participants described a contentious dynamic between nurses and law enforcement officers in the hospital, wrought with argument, stress, and a feeling of coming from "different worlds." The influence of gender was apparent to the female-identified participants, and gender constructs and therefore gender role conflict were critical points of contention. In exploring how nurses and law enforcement officers think about and describe their experiences, nurses and hospital systems may develop a deeper understanding and appreciation of barriers to care for incarcerated patients and of the challenging experiences nurses face in caring for these patients. The nurses' expressed feelings of intimidation, stress, and impaired self-efficacy in this dynamic underscore the need for institutional support and prioritization of caring practices, and identification of the ways in which carceral practices impair care, as well as nurses' safety.

(Re)defining nursing leadership: On the importance of parrhèsia and subversion.

AIM: Through a review of philosophical and theoretical constructs, this paper offers insight and guidance as to ways in which nurse leaders may operationalize advocacy and an adherence to nursing's core ethical values. BACKGROUND: The US health care system works in opposition to core nursing values. Nurse leaders are obliged to advocate for the preservation of ethical care delivery. EVALUATION: This paper draws upon the philosophies of Fromm, Foucault, and Deleuze and Guattari to critically review the functions of nurse leaders within a capitalist paradigm. KEY ISSUE: Key emergent issues in the paper include health care and capitalism and the nurse leader's obligations towards advocacy. CONCLUSION: The nurse leader acts as parrhèsia in viewing truth telling as a duty critical to improving the lives of patients. Ramifications of the decisions by those in power have even greater impact in institutions that serve those with little to no political agency. IMPLICATIONS FOR NURSING MANAGEMENT: The nurse leader has a freedom and platform that their patients do not and must take the courageous risk of choosing to speak. This paper serves as a call to action for nurse leaders to urgently address the current state of US health outcomes.

Hospitals as total institutions.

The image of the hospital is presented to the public as a place of healing. Though the oft-criticized total institutions of the past have been notably dismantled, the totalizing practices therein are now operationalized in the health care system. Through the lens of Erving Goffman, this article offers ways in which health care institutions operationalize totalizing practices, contributing to the mortification of patients and nurses alike in service to the bureaucratic machine. This article examines the ways in which totalizing practices may disrupt the agency of both patients and nurses alike.

Implementation of an Emergency Department-Embedded Infusion Center for the Administration of Monoclonal Antibody Therapy in Patients With Early COVID-19 Infection.

The coronavirus disease 2019 (COVID-19) pandemic has tested nurse staffing and other resources necessary for lifesaving treatment. The emergency use authorization in November 2020 of bamlanivimab as monotherapy and casirivimab/imdevimab as combination therapy brought hope to many as an option for outpatients at risk for severe illness. However, logistical concerns were soon revealed, because safe administration requires a location where patients can receive specialized care and monitoring for a period of 2 hours. This type of therapy would normally be offered at an outpatient infusion center. These centers often serve persons who are immunocompromised, and introducing COVID-19-positive individuals could threaten the safety of this population. This article describes the deployment of an emergency department-embedded infusion center set up for the purpose of supporting community members and providers electing for this treatment option.

'This Is Not a Patient, This Is Property of the State': Nursing, ethics, and the immigrant detention apparatus.

This paper opens with first-hand accounts of critical care medical interventions in which detainees, in the custody of U.S. Immigration and Customs Enforcement (ICE), are brought to the emergency department for treatment. This case dramatizes the extent to which the provision of ethical and acceptable nursing care is jeopardized by federal law enforcement paradigms. Drawing on the scholarship of Michel Foucault and Giorgio Agamben, this paper offers a theoretical account of the power dynamics that inform the health care of patients who find themselves caught in the custodial scaffolding of a vast immigration and detention apparatus. It offers an analysis of the display of sovereign and biopolitical power over the lives (and deaths) of detainees (Foucault), as well as the ways these individuals are reduced to "bare life" under the political pretext of an emergency or "state of exception" (Agamben). Our purpose here is both theoretical and practical: to better understand the often hidden agency or impersonal "will" exercised by the immigrant detention system, but also to equip clinicians in these and cognate facilities (e.g., prisons) with the critical tools by which they might better navigate incommensurable paradigms (i.e., care vs. custody) in order to deliver the best care while upholding their ethical duties as a care provider. This is all the more pressing because hospitals are not sanctuaries and given the incursion of federal law enforcement agents, nurses may find themselves conscripted as de facto agents of the state.