Digital ethical reflection in home nursing care: Nurse leaders' and nurses' experiences.

BACKGROUND: Nurse leaders increasingly need effective tools that facilitate the prioritisation of ethics and help staff navigate ethical challenges and prevent moral distress. This study examined experiences with a new digital tool for ethical reflection, tailored to improve the capabilities of both leaders and employees in the context of municipal long-term care. AIM: The aim was to explore the experiences of nurse leaders and nurses in using Digital Ethical Reflection as a tool for ethics work in home nursing care. RESEARCH DESIGN: The study employed a qualitative design, incorporating individual and focus group interviews for data collection. Qualitative content analysis was used to analyse the data. PARTICIPANTS AND RESEARCH CONTEXT: The participants comprised six nurse leaders and 13 nurses, representing six home care zones across two Norwegian municipalities. ETHICAL CONSIDERATIONS: The study involved informed, voluntary participation and was approved by the Norwegian Agency for Shared Services in Education and Research. FINDINGS: Four themes were developed: a constant walk on the edge between engagement and discouragement and lost in translation describe the process, while tuning in to the ethical dimension and navigating ethical uncertainties illuminate the experienced significance of Digital Ethical Reflection. CONCLUSION: Success with Digital Ethical Reflection in home nursing care depends on clear leadership planning, nurses' understanding of the tool's purpose, and active use of digital registrations. Support from ethically interested nurses enhances overall engagement. Further research is needed to explore the potential of Digital Ethical Reflection as an additional tool in long-term care ethics work.

Digital ethical reflection in long-term care: Leaders' expectations.

BACKGROUND: Healthcare leader support and facilitation for ethics work are of great importance for healthcare professionals' handling of ethical issues, moral distress, and quality care provision. A digital tool for ethical reflection in long-term care was developed in response to the demand for appropriate tools. RESEARCH AIM: This study aimed to explore healthcare leaders' expectations of using a digital tool for ethical reflection among their home nursing care staff. RESEARCH DESIGN: A qualitative research design with vignettes and focus group interviews was used. The data were analyzed using reflexive thematic analysis. PARTICIPANTS AND RESEARCH CONTEXT: The sample comprised ten healthcare leaders from municipal long-term care in Norway. ETHICAL CONSIDERATIONS: Participation was voluntary and based on informed consent. The Norwegian Agency for Shared Services in Education and Research approved this study. FINDINGS: The analysis resulted in the development of three themes representing leaders' expectations of the tool: (i) giving staff a voice, (ii) revealing ethics in practice, and (iii) keeping the pot boiling. DISCUSSION: Leaders must be informed about the ethical issues experienced to engage in supportive measures for their staff. Digital channels can increase the democratization, safety, and efficiency of communication between employees and leaders and increase awareness of ethical aspects in daily care work. The leaders had positive expectations of employees' activities and benefits from using the tool for ethical reflection. However, they admitted that realizing the tool's potential to ensure continuity in ethics work requires considerable organizational and leader involvement. CONCLUSIONS: This study shows that healthcare leaders are open to digital solutions for managing ethics work in home nursing care. Both opportunities and important prerequisites for successfully implementing the digital tool were identified.

Nurses and global health responsibility: In light of the COVID-19 pandemic and the war in Ukraine.

AIM: The aim of this paper was to reflect on global ethical challenges for nurses in light of the COVID-19 pandemic and the war in Ukraine and to discuss 'Nurses and Global Health', a new element in the revised ICN Code of Ethics for Nurses, 2021, and its implications for nurses. BACKGROUND: The authors participated in the latest revision of the Code. When we were revising the ICN Code of Ethics, there was neither an ongoing pandemic nor a war in Europe. SOURCES OF EVIDENCE: Relevant scientific articles and other academic literature, documents from international organisations, and authors' views. DISCUSSION: The discussion emanated from our reflections on how to actually apply the ICN Code of Ethics, i.e., moving the words from the document itself into everyday practice, in light of the COVID-19 pandemic and the war in Ukraine. In the Code, the nurse's responsibility is highlighted, but there is little or no instruction on how to undertake it. CONCLUSION AND IMPLICATIONS FOR NURSES: The ICN Code of Ethics needs to be operationalised through ethical reflection and discussion in all contexts where nurses work, from policy level to the care environment.

Developing and Testing Digital Ethical Reflection in Long-Term Care: Nurses' Experiences.

Introduction: Nurses working in municipal long-term care face ethical challenges that can lead to moral distress and discomfort for the nurse and affect the quality of patient care. Tools and methods that contribute to increased ethical awareness and support for nurses dealing with moral issues are lacking. Technological innovations may be suitable for ethics work, but little research has been conducted on how such solutions could be designed or their potential benefit. Therefore, this study contributes knowledge about the development and testing of a digital tool for ethics support among nurses. Objective: To investigate how digital ethical reflection can support ethics work among nurses working in long-term care. Methods: A digital ethical reflection tool was designed and tested in nursing homes and home nursing care in collaboration with two Norwegian municipalities. The study used sequential explanatory mixed-methods design. Over a 6-week period, at the end of each shift, nurses digitally reported the ethical challenges they had experienced. Their responses and experiences were described using descriptive statistics. Additionally, focus group interviews were conducted and analyzed using reflexive thematic analysis (TA). Results: During the study period, 17 nurses reported a total of 223 registrations, with 24.8% stating that they had been in an ethically difficult situation. The digital reporting was perceived as practically applicable and helped to increase nurses' awareness of morally charged situations. The value of the registrations was found to depend on manager participation and the application of the obtained information. The participating nurses become aware that they lacked an arena for meaningful dialogue with and recognition from their manager. Conclusions: Information obtained through digital reflection can form the basis for ethical reflections at the departmental level. Digital reflection has the potential to become a tool for managers in their support for employees facing ethical challenges when providing long-term care.

Interprofessional care for the ICU patient's family: solitary teamwork.

The aim of this study was to explore how interprofessional family care by ICU teams was reflected in their daily work. Data were collected from four ICUs in Norway. Fieldwork and focus groups with ICU nurses and physicians were conducted in addition to dyadic and individual interviews of surgeons and internists. In line with a constructivist grounded theory approach, the core category "solitary teamworking" was constructed. Together with three sub-categories, proximity and distance, silent interprofessional work and a connecting link, this core category conceptualizes interprofessional family care as a form of contradictory cooperation where physicians and nurses alternate between working alone and as a team. The sub-categories reveal three notable characteristics of interprofessional family care: (1) it is emotionally challenging, affected by proximity and distance to the families and between the clinicians, (2) it is silent, at a strategic and organizational level, and (3) nurses and family members have an essential role as a connecting link in the ICU team. Interprofessional family care needs strong involvement by an organization that supports and prioritizes family care, includes family members as an active part of the ICU team and emphasizes interprofessional dialogue.

ICU nurses´ lived experience of caring for adult patients with a tracheostomy in ICU: a phenomenological-hermeneutic study.

BACKGROUND: The care of adult patients with a tracheostomy in intensive care unit is complex, challenging and requires skilled intensive care unit nurses. ICU nurses' live experience is scarcely known. This study aimed to describe the lived experience of intensive care unit nurses of caring for adult patients with a tracheostomy in intensive care unit. METHODS: This study employs a qualitative design. In-depth interviews were conducted with a purposive sampling of 6 intensive care unit nurses from a medical-surgical ICU of a university hospital in Norway who were interviewed. Data was analyzed and interpreted using a phenomenological-hermeneutic approach. This study was reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ). RESULTS: The interpretation yielded the following themes and subthemes: 1) theme: 'challenges of caring for patients with a tracheostomy' consisted of the sub-themes: 'difficult to communicate/interpret and understand the patient's different forms of expression', 'complicated professional assessments', 'caring with patience', and 'collaborating with patient regarding challenges. 2) theme: 'the satisfaction from providing care to patients with a tracheostomy' consisted of the sub-themes: 'working with intensive care patients is instructive' and 'importance to motivate'. CONCLUSIONS: ICU nurses experienced ambivalent feelings while caring for adult patients with a tracheostomy in ICU. They perceived caring as demanding owing to communication and collaboration at the same time, they experienced satisfaction while they strived to provide proper care and motivation. The identified challenges would lead to further improvement in nurses' experiences and, in turn, the quality-of-care for patients with a tracheostomy. Awareness of these challenges is crucial to understand the need for an effective communication strategy to improve the quality and safety of adult patients with tracheostomy in ICU.

Multiple perspectives and dialogue in understanding experiences of living with eating disorders: Two narratives-four unpackings.

BACKGROUND: This is a response to Conti et al.'s article, "Listening in the dark: why we need stories of people living with severe and enduring anorexia nervosa" (published in JED, 2016), and its call for relational metaphors and a relational approach to supplement the traditional medical/psychological diagnostic language used to describe the life experiences and complex emotions of people affected by an eating disorder. METHODS: Four authors with different backgrounds unpack two narratives, 'The Prima Donna with the Green Dress' and 'Breaking down the Wall', both narrated during fieldwork in multifamily therapy. The narratives are unpacked from the perspective of a therapist within multifamily therapy, a researcher who conducted the fieldwork, a researcher based in phenomenology and a researcher based in narrative inquiry. The authors enter into dialogue with the narratives, and with each other. RESULTS: The four authors focus on different elements within the narratives and understand them differently. One, focuses on strength and pride, and art expression as a different form of language for people living with an eating disorder. Another, on the experience of isolation, boundaries, and balancing openness and closedness. A third, sees the narratives as expressing a wish to see and be seen, and the fourth focuses on the absence of, and longing for, a shared space to explore. CONCLUSION: The aim is not to reach a correct or shared interpretation of the narratives but to explore how different perspectives may contribute to different insights, not only about one family in particular but about, more generally, the experiences of people living with an eating disorder. Our work shows the significance of engaging with multiple perspectives and dialogue as supplements to the traditional medical/psychiatric diagnostic language in both clinical practice and research.

In this article, four authors read and unpack two narratives from fieldwork in a multifamily therapy programme for adults with a severe eating disorder. The authors have different professional, theoretical and methodological backgrounds. The aim is not to reach a shared understanding of the narratives, but rather to explore how different perspectives contribute to different insights. Multiple perspectives and dialogue may shed light on people's experiences of living with a severe eating disorder in both clinical practice and research.

The experiences and strategies of parents' of adults with anorexia nervosa or bulimia nervosa: a qualitative study.

BACKGROUND: Caring for an individual with an eating disorder involves guilt, distress and many extra burdens and unmet needs. This qualitative study explored the experiences of parents with adult daughters suffering from anorexia nervosa or bulimia nervosa and the strategies they adopted. A subsidiary aim of the study was to explore the relationship between the caregivers' perceived need for professional support and the support they reported receiving in practice from the health services. METHODS: Semi-structured interviews were conducted with 11 mothers and fathers from across Norway. Data collection, coding and analysis was conducted using the principles of constructivist grounded theory in an iterative process. The main concern shared by participants was identified by this process and their "solution" to the main concern then formed the content of the core category. RESULTS: ″Wearing all the hats″ emerged as the core category, indicating that the parents have to fulfil several roles to compensate the lack of help from health services. The three subcategories: "adapting to the illness", "struggling for understanding and help" and "continuing to stay strong" described how the participants handled their situation as parents of adult daughters with eating disorders. CONCLUSIONS: In daily life, the parents of adults with eating disorders have to attend to a wide range of caregiver tasks to help their ill daughters. This study suggests that the health services that treat adults with eating disorders should be coordinated, with a professional carer in charge. The parents need easy access to information about the illness and its treatment. They also need professional support for themselves in a demanding situation.

"Breaking down the wall" patients` and families` experience of multifamily therapy for young adult women with severe eating disorders.

BACKGROUND: This paper addresses patients` and families` experience of multifamily therapy (MFT) for young adults (18-22) with an eating disorder (ED). EDs are serious illnesses leading to lowered quality of life for the patient and their family. The Regional Centre for Eating Disorders (RESSP) at Nordland Hospital in Bodø, Norway has developed an adjunct psychotherapeutic approach for the treatment of young adult patients with severe EDs. The patient's family members take part in the multifamily therapy (MFT) group programme. METHODS: The aim of the study was to explore patients` and families` experience of MFT for young adult women with severe EDs. A Grounded Theory (GT) approach was used. Data were collected by field observations in two MFT groups, qualitative group interviews and qualitative individual interviews with patients and their family members. Data were analysed using the constant comparative method. The data analysis consisted of open and selective coding and memo writing. RESULTS: Two main categories were identified: 'Connectedness and recognition' and 'Opening up and sharing`. MFT was described as a space for recognition within which it was possible to speak of things happening in the family with others with similar difficulties. It felt good and freeing, but also painful, to meet others with similar experiences. The participants had in common a considerable loneliness because it is difficult for outsiders to grasp what it is like in a home dominated by an ED. The meeting with other families created an underlying safety. The participants received help to distinguish between realistic and unrealistic concerns and learned about openness and communication in relation to their daughter. Some women with EDs said that MFT was most important for the parents but also had been good for them as things had become better at home. CONCLUSION: The participants reported that their family had become better at talking to each other after having been in MFT. As a result, they were able to speak more openly about difficult things and share feelings. This gave rise to increased understanding. The study shows that MFT was found to be valuable and important. Never before had these families had such an opportunity, something so directly tailored to them. MFT for adults can be developed further and used in other groups, such as those concerning other chronic illnesses.

Information concerning ICU patients' families in the handover-The clinicians' «game of whispers¼: A qualitative study.

AIMS AND OBJECTIVES: To explore how information concerning ICU patients´ families is included in the ICU clinicians' daily handover. BACKGROUND: Handover refers to the transfer of information and care responsibility between clinicians. An effective and precise handover are of great importance to ensure quality of care. Although improvements in handovers have received increasing attention in recent decades, little is known about how information about ICU patients' family members is included in handovers. DESIGN: A qualitative study using Charmaz' constructivist grounded theory approach. METHODS: Data were gathered through participant observation, focus groups, dyadic and individual interviews of physicians and nurses from four ICUs in different Norwegian hospitals. The data consist of 270 observation hours, seven focus groups, three dyadic interviews and two individual interviews. Field notes and transcribed interview data were analysed using constructivist grounded theory approach. COREQ checklist was applied as reporting guideline for this study. FINDINGS: "A game of whispers" emerged as the core category, representing missing information about the patient's family during the handover. Together with three subcategories: "documentation dilemmas," "being updated" and "talking together," the core category explains how transfer of family-related information between clinicians is continually processed and resolved. CONCLUSIONS: This study indicates challenges related to appropriate and high-quality handover concerning ICU patients´ families. Oral handovers are essential in terms of clinicians' need to elaborate on written information and update each other. However, oral transmission involves a high risk of information loss during the handover. Written documentation about the family seems to be inadequate and poorly structured. RELEVANCE TO CLINICAL PRACTICE: The study findings suggest a need for increased awareness in practice and research of the importance of transferring appropriate and reliable information about patients' families between ICU clinicians. User-friendly handover tools and patient records that include information on patients' family members should be developed.

Field-testing the Euro-MCD Instrument: Experienced outcomes of moral case deliberation.

BACKGROUND: Moral case deliberation is a form of clinical ethics support to help healthcare professionals in dealing with ethically difficult situations. There is a lack of evidence about what outcomes healthcare professionals experience in daily practice after moral case deliberations. The Euro-MCD Instrument was developed to measure outcomes, based on the literature, a Delphi panel, and content validity testing. To examine relevance of items and adequateness of domains, a field study is needed. AIM: To describe experienced outcomes after participating in a series of moral case deliberations, both during sessions and in daily practice, and to explore correlations between items to further validate the Euro-MCD Instrument. METHODS: In Sweden, the Netherlands, and Norway, healthcare institutions that planned a series of moral case deliberations were invited. Closed responses were quantitatively analyzed. The factor structure of the instrument was tested using exploratory factor analyses. ETHICAL CONSIDERATIONS: The study was approved in Sweden by a review board. In Norway and the Netherlands, data services and review boards were informed about the study. RESULTS: The Euro-MCD Instrument was completed by 443 and 247 healthcare professionals after four and eight moral case deliberations, respectively. They experienced especially outcomes related to a better collaboration with co-workers and outcomes about individual moral reflexivity and attitude, both during sessions and in daily practice. Outcomes were experienced to a higher extent during sessions than in daily practice. The factor structure revealed four domains of outcomes, which did not confirm the six Euro-MCD domains. CONCLUSION: Field-testing the Euro-MCD Instrument showed the most frequently experienced outcomes and which outcomes correlated with each other. When revising the instrument, domains should be reconsidered, combined with theory about underlying concepts. In the future, a feasible and valid instrument will be presented to get insight into how moral case deliberation supports and improves healthcare.

An Aristotelian view of therapists' practice in multifamily therapy for young adults with severe eating disorders.

BACKGROUND: Eating disorders are serious conditions which also impact the families of adult patients. There are few qualitative studies of multifamily therapy with adults with severe eating disorders and none concerning the practice of therapists in multifamily therapy. OBJECTIVES: The aim of the study is to explore therapists' practice in multifamily therapy. RESEARCH DESIGN AND PARTICIPANTS: A grounded theory approach was chosen. Data were collected through participant observation in two multifamily therapy groups and qualitative interviews with the therapists in those groups. ETHICAL CONSIDERATIONS: The study conforms to the principles outlined in the Declaration of Helsinki. All participants in the multifamily therapy groups received information about the research project and signed consent forms. The data are treated confidentially and anonymised. FINDINGS: The core category was identified as 'having many strings to one's bow', consisting of three subcategories: 'planning and readjusting', 'developing as therapist and team' and 'regulating the temperature of the group'. This article discusses the empirical findings in the frame of Aristotelian virtue ethics.

Mothers' experiences of having a premature infant due to pre-eclampsia.

AIM: Pre-eclampsia can lead to premature birth aimed at saving mothers' and infants' lives. Few studies have addressed how women with serious pre-eclampsia experience to become mothers to a premature infant. The aim was to describe the phenomenon of mothers' experience of being a seriously ill with pre-eclampsia and on the same time becoming a mother of a premature infant. METHODOLOGY: A reflective phenomenological lifeworld approach with a descriptive design was used. Nine mothers were interviewed twice, between 6 and 24 days and 16 days to 16 weeks postpartum. The analysis was done by finding meaning units, and then contemporary clusters were made. The process was a movement between figure and background. The essence with its constituents emerged. FINDINGS: Being a seriously ill mother of a premature infant requires journeying through physical and psychological suffering to be able to care and take responsibility for their beloved infants. The essence had the following constituents: conflicting feelings concerning giving birth, reflecting upon the borderline of life, longing for the infant, becoming a mother in actuality and experiencing physical exhaustion. CONCLUSION: Because of the acuteness of the birth and the infant's prematurity, the mothers had various feelings about becoming mothers. Existential issues concerning life and death were triggered regarding their own lives and those of their infants. Their experiences are different from those of other NICU mothers; their illnesses initially restricted them from being with their infants. The mothers found that their own health and the fact that their infants were premature and had to stay in the NICU restricted them from being able to take care of their infants. While they recovered, they strived to act as they felt a real mother should.

Tailoring reablement: A grounded theory study of establishing reablement in a community setting in Norway.

Reablement is an interprofessional, home-based rehabilitation service that aims to enable senior residents to cope with everyday life and to prevent functional impairments. Systematic accounts of what practitioners actually do when establishing reablement are lacking. This study aims to generate a grounded theory of practitioners' patterns of action when establishing reablement. The study is located in Norway, and grounded theory is the methodological approach. Data were collected from January 2014 to August 2016 through participant observations, focus group interviews and individual interviews. Informants are municipal healthcare employees in different organisational areas associated with the process of establishing reablement services (managers of conventional home care and representatives from the administration and service-provider offices). Altogether, 17 individuals are interviewed. The empirical data are analysed several times using open, selective and theoretical coding. The grounded theory, "tailoring reablement," includes three phases-replicating, adapting and establishing-and the strategies of collaborating, developing knowledge, habituating and filtering. The theory of tailoring reablement also includes the impact of the contextual factors. The study seeks to bridge the gap between research and practice. The theory of tailoring reablement emerges from an inductive approach and theorises participants' actions. The theory focuses on the phases from innovation to implementation. Establishing a new service model in a complex welfare setting requires a wide range of actors and agencies. Tailoring reablement also requires flexibility and professional autonomy. It is important to create terms and conditions for this within a stringent health and care service. The insights of this study have implications for practice development of reablement and can fit other public sector fields.

Care-managers' professional choices: ethical dilemmas and conflicting expectations.

BACKGROUND: Care-managers are responsible for the public administration of individual healthcare decisions and decide on the volume and content of community healthcare services given to a population. The purpose of this study was to investigate the conflicting expectations and ethical dilemmas these professionals encounter in their daily work with patients and to discuss the clinical implications of this. METHODS: The study had a qualitative design. The data consisted of verbatim transcripts from 12 ethical reflection group meetings held in 2012 at a purchaser unit in a Norwegian city. The participants consist of healthcare professionals such as nurses, occupational therapists, physiotherapists and social workers. The analyses and interpretation were conducted according to a hermeneutic methodology. This study is part of a larger research project. RESULTS: Two main themes emerged through the analyses: 1. Professional autonomy and loyalty, and related subthemes: loyalty to whom/what, overruling of decisions, trust and obligation to report. 2. Boundaries of involvement and subthemes: private or professional, care-manager or provider and accessibility. CONCLUSIONS: Underlying values and a model illustrating the dimensions of professional responsibility in the care-manager role are suggested. The study implies that when allocating services, healthcare professionals need to find a balance between responsibility and accountability in their role as care-managers.

Fathers' experience of starting family life with an infant born prematurely due to mothers' severe illness.

OBJECTIVE: To describe fathers' experiences of starting family life with an infant delivered prematurely out of necessity of saving the mother's and infant's lives due to the mother's severe preeclampsia. METHODS: A descriptive, qualitative design was used. Six fathers were interviewed twice: from 6 to 24 days and from 4 to 22 weeks after delivery. Data were transcribed verbatim and analyzed using a reflective lifeworld research approach. RESULTS: The essence of the fathers' experiences of establishing a family with a seriously ill mother and a premature infant can be described as a process of becoming a family through reflection on life and death in a context of separation. The essence specifically comprised the following constituents: (1) starting fatherhood facing existential issues, (2) connecting the family, (3) becoming familiar with your infant, and (4) becoming a father in a public area. CONCLUSIONS: The fathers were able to develop their relationship to their infants; this emphasizes the importance of the fathers being able to spend their time in the NICU. The privacy of the fathers were more or less challenged, health professionals should be aware of individualize their approach to the fathers. The study reveals that family life started with separation. Health professionals should try to ensure that the family should be together. Mutual guidelines between the wards that treats mother and child should be implemented. When new mother and child-centers are planned a family friendly environment should be prioritized.

An Integrative Review of Mothers' Experiences of Preeclampsia.

OBJECTIVE: To describe and synthesize the extant research on women's experiences with preeclampsia into the postpartum period, when birth is necessary to save the mother's or infant's life. DATA SOURCES: The PubMed, PsycINFO, CINAHL, and ISI Web of Science databases were searched for relevant articles published between 2004 and 2014. STUDY SELECTION: Although a comprehensive search was performed, only eight studies were found that answered the research question and were included in the review. DATA EXTRACTION: Data were extracted and analyzed from each article that addressed women's experiences of pre-eclampsia: authors, year, country, study purpose, design, sample size, setting, main focus, data collection method, study findings, and limitations. DATA SYNTHESIS: The following themes emerged from the synthesis of how women experience severe preeclampsia: (a) From Feeling Fear and Closeness to Death to Feeling Hope, (b) Relationship With the Infant, (c) Separation From Loved Ones, and (d) Communication With Health Professionals. CONCLUSION: Fear and feeling close to death characterized the experience of childbirth for many of these women, and the premature birth was a shock for many. Having a newborn in the NICU was experienced as a transition from fear to hope as the newborn's life was sustained outside the womb. Separation of the mother from the newborn when one or both need special care remains a problem. Health care professionals must ensure that women in this situation receive the information and support they need and that the information is understood. This review revealed that more research is necessary regarding this specific mother-infant dyad and their families in the context of Western countries and developing countries.

Ethical challenges related to next of kin - nursing staffs' perspective.

BACKGROUND: Patients in clinical settings are not lonely islands; they have relatives who play a more or less active role in their lives. OBJECTIVES: The purpose of this article is to elucidate the ethical challenges nursing staff encounter with patients' next of kin and to discuss how these challenges affect clinical practice. RESEARCH DESIGN: The study is based on data collected from ethical group discussions among nursing staff in a nursing home. The discussions took place in 2011 and 2012. The data were analysed and interpreted by using hermeneutic methodology. ETHICAL CONSIDERATIONS: All the data have been anonymised and handled with confidentiality. Written informed consent was obtained from all participants. FINDINGS: Ethical challenges relating to patients' next of kin were found to be an issue frequently discussed in the groups. Our findings indicate that next of kin have different characteristics, categorised as 'the professionals' and 'the shadows'. In this article, we will describe the next of kin's characteristics and the ethical challenges and practical implications that nursing staff experience in this connection. DISCUSSION: We will discuss the findings in the light of the four basic principles of medical ethics and propose interventions to help nurses manage ethical challenges related to next of kin. CONCLUSION: The study reveals the need to enhance nursing staffs' communicative and ethical skills on an individual level, but most importantly, to establish routines in clinical settings for informing and following up next of kin in a systematic and structured way.

Ethical challenges in everyday work with adults with learning disabilities.

BACKGROUND: Healthcare providers caring for learning-disabled individuals in institutions face challenges of what is right or wrong in their daily work. Serving this group, it is of utmost importance for the healthcare staff to raise awareness and to understand how ethical values are at stake. RESEARCH QUESTION: What ethical challenges are discussed among healthcare providers working with adults with learning disabilities? RESEARCH DESIGN: The study had a qualitative and investigative design. PARTICIPANTS AND RESEARCH CONTEXT: The study was conducted in a community institution for adults with learning disabilities. Participants were healthcare providers joining regular focused group discussions. Two groups participated and each group consisted of six participants. The conversations were taped and transcribed. ETHICAL CONSIDERATIONS: The study was reported to Norwegian Social Science Data Services and was approved by the regional ethics committee. FINDINGS: Findings are presented in four themes: (a) feeling squeezed between conflicting actions, (b) being the client's spokesman, (c) searching shared responsibility, and (d) expecting immediate and fixed solutions. The healthcare providers wanted to be the clients' advocates. They felt obliged to speak up for the clients, however, seeking for someone with whom to share the heavily experienced responsibility. Data likewise revealed that the group discussions created expectations among the healthcare providers; they expected smart and final solutions to the problems they discussed. DISCUSSION: The discussion focuses on everyday ethical challenges, the meaning of being in-between and share responsibility, and the meaning of ethical sensitivity. CONCLUSION: Ethical challenges can be demanding for the staff; they might feel squeezed in-between contradictory attitudes or feel alone in decision-making. Frequent conversations about ethical challenges do not solve the ethical problems here-and-now, but they do visualize them. This also visualizes the staff's need for support.

"Values that vanish into thin air": nurses' experience of ethical values in their daily work.

The objective of this study was to examine how nurses experience ethical values as they are expressed in daily practice in a Norwegian hospital. A growing focus in Western healthcare on effectiveness, production, and retrenchment has an influence on professional nursing standards and nursing values. Lack of resources and subsequent ethically difficult prioritizations imply a strain on nurses. This study is qualitative. Data collection was carried out by conducting 4 focus group interviews. The data was analyzed using content analysis. The results are presented in two main themes: (1) values and reflection are important for the nurses; (2) time pressure and nursing frustrations in daily work. The results demonstrate that nurses believe the ethical values to be of crucial importance for the quality of nursing; however, the ethical values are often repressed in daily practice. This results in feeling of frustration, fatigue, and guilty conscience for the nurses. There is a need for changes in the system which could contribute to the development of a caring culture that would take care of both patients and nurses. In an endeavour to reach this goal, one could apply caritative leadership theory, which is grounded on the caritas motive, human love, and mercy.