Students who witness critical events in the clinical setting: Recommendations for prevention of psychological trauma.

BACKGROUND: Student nurses often do not receive adequate preparation, support, and debriefing related to witnessing or experiencing critical events in the clinical setting. PURPOSE: The purpose of this analysis was to describe the experiences of student nurses who have witnessed critical events in the clinical setting, the support and preparation they received, and staff and faculty actions they perceived as facilitating or hindering their processing of the event. METHODS: This is a sub-analysis of a Straussian Grounded Theory qualitative study. RESULTS: Staff and faculty actions that helped and hindered the processing of the critical event were identified at four time points: pre-event, during the critical event, immediately post-event, and in the days and weeks following. CONCLUSIONS: Students exposed to critical events during their clinical rotations can experience psychological trauma. If unresolved, this can result in new nurses entering the profession already in distress. Preparation and support for witnessing critical patient events should start at the beginning of nursing school. During critical patient events, students need faculty or staff to be actively present to explain the event and support the student throughout the event. Immediate debrief and follow-up is recommended and should continue weeks or months after the event.

Nursing Student Success: A Concept Analysis.

AIM: The aim of this concept analysis was to develop a comprehensive definition of nursing student success. BACKGROUND: Nursing student success has traditionally been viewed as timely program completion and passing the licensure exam on the first attempt. Little consideration has been given to holistic indicators of success that are inclusive of student well-being and mastery of self-care skills. METHOD: Nursing student success was examined using Walker and Avant's eight-step process of concept analysis. RESULTS: This concept analysis defined nursing student success in a holistic manner characterized by the achievement of performance standards, acquisition of nursing knowledge, skills, and competencies, and attainment of educational goals while experiencing a state of personal thriving. CONCLUSION: This concept analysis highlights the need for academic programs and accrediting bodies to embrace holistic perspectives of nursing student success that are inclusive of student well-being and mastery of self-care skills.

Conceptualizing transgender and gender-diverse older adults as a vulnerable population: A systematic review.

BACKGROUND: While extant literature clearly illustrates the negative experiences of transgender and gender-diverse (TGD) people, the intersection between TGD identity and older age in producing vulnerability is poorly understood. The Vulnerable Populations Conceptual Model (VPCM) provides a framework for identifying vulnerable communities. Understanding access to resources, relative risks, and health status experienced by TGD older adults is critical in developing person-centered interventions. METHODS: A systematic review using PRISMA guidelines was used. CINAHL, Medline, PubMed, and PsycINFO were searched for studies published from 2017 to 2022. RESULTS: Of the seventeen articles included, no articles were based from a nursing journal. Synthesis of findings described TGD older adults as a vulnerable population with limited access to resources and several risks leading to poor health status. CONCLUSION: Identifying TGD older adults as a vulnerable population is critical to understand their unique needs. The findings underline implications in nursing education, practice, and research.

Shaming: A Concept Analysis.

Nurses in a variety of settings frequently use behavior modification strategies to promote health behavior change. Shaming is one such behavior modification tool, but its use in nursing is poorly understood. A concept analysis using Walker and Avant's method was performed. After an extensive literature review, a conceptual definition of shaming is proposed and defining attributes, antecedents, and consequences are presented. Shaming is also differentiated from related concepts often used synonymously such as stigmatization and incivility. Shaming as a behavior modification strategy is incongruous with nursing values and its utilization in nursing warrants further investigation.

Caring in the Context of Risk: Moving Beyond Duty.

Hospital-based nurses face many occupational risks. In the early days of the coronavirus disease-2019 (COVID-19) pandemic, questions were raised regarding nurses' responsibilities to provide care in the context of risk of exposure to this infectious disease. In the United States, these questions were answered relatively swiftly using a deontological framework. If nurses did not have access to appropriate personal protective equipment, they were not duty bound to provide nursing care to patients with a known infection. Another occupational risk hospital-based nurses face is exposure to patient violence. Questions about nurses' responsibilities to provide care in the context of this occupational risk have not been addressed. The purpose of this article is to examine these 2 occupational risks and ethical decision-making frameworks that can be used to answer questions about the provision of nursing care in the face of personal risk. While useful in the context of COVID-19, a duty-based framework seems insufficient to capture the contextual nuances and moral complexity of providing nursing care to hospitalized patients who exhibit violent behavior. Professional duties are explored as are other ethical frameworks. Ethics of the everyday, virtue ethics, and care ethics are introduced as additional perspectives that can help inform nurses' decision-making and actions when they are exposed to occupational risks such as patient violence and COVID-19.

Liberal arts and ethics education in nursing: A national survey.

BACKGROUND: Liberal arts education is foundational to nursing yet its integration in nursing curriculum is unknown. Ethics content is crucial in nursing education and holds potential as an area in which integration can occur. Research on the liberal arts and ethics in nursing education is lacking. PURPOSE: The purpose of this study was to conduct an assessment of liberal arts, particularly ethics, education in schools of nursing. METHODS: A cross-sectional, descriptive design was used. An anonymous, online survey was sent to representatives from 871 accredited schools of nursing across the United States. RESULTS: Representatives from 218 schools responded. Most programs covered liberal arts content in pre/corequisites and embedded ethics content. Most faculty members teaching ethics had no ethics training/education. There was a mismatch between what respondents reported as the most important ethics content to cover and the content covered. Common teaching strategies used to deliver ethics content were case studies, textbooks, small group discussions, and lectures. CONCLUSION: Liberal arts content can be disconnected from nursing education. There is a need for consensus regarding ethics education in nursing. There is a need for research related to the integration of the liberal arts and research on ethics in nursing education in general.

Stigmatization in nursing: Theoretical pathways and implications.

Stigmatization of patients exists in nursing and results in less than optimal nursing care and poor patient outcomes. It is also a violation of our code of ethics. In order to eliminate stigmatization from nursing practice, it is necessary to understand how it develops. Two possible theoretical pathways are proposed to explain the development of stigmatization in nursing. These pathways are informed by a conceptual understanding of stigma and theories of professional socialization, professional formation, symbolic interactionism, and social cognitive theory. Re-labeling and role-taking and moral disengagement are proposed as two possible processes that may lead to stigmatization of patients. Both proposed pathways have implications on professional socialization, formation, and the development of professional identity. Devoting attention to and reframing normative behavioral expectations, eliminating labeling, developing empathy, focusing on relationships, and cultivating ethical comportment and moral maturity during nursing formation may reduce the stigmatization of patients by nurses.

Student Nurses' Experiences of Critical Events in the Clinical Setting: A Grounded Theory.

BACKGROUND: Nursing students often experience critical events in the clinical setting and clinical instructors may not be prepared to adequately support them. These students often feel alone and abandoned, increasing their risk of psychological distress. PURPOSE: A grounded theory study was conducted to explore pre-licensure nursing students' experiences of critical events in the clinical setting. Specific attention was paid to understanding how they are prepared for and supported before, during, and after critical events, and their experiences of psychological distress and psychological recovery. METHOD: Strauss and Corbin's Grounded Theory methodology was used for this study. RESULTS: Fourteen undergraduate student nurses from universities in the western United States were interviewed. Ten concepts were identified, and a theory of Student Nurses' Experiences of Critical Events in the Clinical Setting emerged. CONCLUSION: Findings indicate that student nurses need active instructor and/or staff support during critical events, and pre-briefing whenever possible. Debriefing positively affected students' post-event stress response and lack of debrief was associated with post-event psychological distress. Support for students exposed to critical events during clinical experiences should continue in the days, weeks, and months following the event; clinical instructors need to be prepared to provide this support. All faculty members should monitor students for signs of psychological distress and better support students' mental health and emotional wellbeing.

Acute care nurses' attitudes toward nursing students with disabilities: A focused ethnography.

Discrimination towards individuals with disabilities is problematic within nursing. There have been calls to increase diversity in nursing and this includes embracing nurses with disabilities. Increasing diversity in nursing requires increasing diversity among nursing students; in this way, nurse educators are gatekeepers to the profession. Clinical education is a crucial element of nursing education, yet there have been very few studies related to the clinical education of nursing students with disabilities. There have been no studies of attitudes of acute care nurse preceptors toward students with disabilities in the United States. This gap is important as the majority of clinical experiences occur in the acute care environment. Utilizing a focused ethnography, semi-structured interviews were conducted with 20 acute care nurses with at least two years' experience precepting students. While positive feelings about nursing students with disabilities were shared, thoughts and behavioral intentions remained negative. Six themes emerged: safety, barriers, otherness, communicating to meet needs, disclosure, and student versus colleague. Attitudinal barriers are the primary barriers faced by individuals with disabilities in becoming and practicing as nurses. Nurses in practice and education must embrace more inclusive attitudes towards individuals with disabilities.

The moral dilemma of interpreting workplace violence.

Workplace violence is a significant problem in healthcare. It was believed that in the context of patient violence nurses faced a moral dilemma regarding conflicting duties to self and patients. A qualitative study was conducted with nurses who experienced physical violence perpetrated by a patient. The aim was to examine the ethical decision-making process nurses used to determine the "right" course of action. Nurses did not perceive the conflict between these two duties as the primary dilemma they faced. They appreciated their patients' vulnerability and the power differential inherent in the RN-patient relationship and maintained that their primary responsibility was patient safety. Interpretation of the event was the primary dilemma they described. Patient violence was framed as a dichotomous experience: an expected part of the job or a crime. The middle space between these two choices was bounded by a fuzzy, porous, extremely difficult to interpret line. The dichotomous interpretation resulted in a perception of dichotomous responses: do nothing or file criminal charges. Violence in the context of the RN-patient relationship is a complex phenomenon involving a host of factors. We need to direct more attention to this complexity, to individualized responses to workplace violence, and to depolarizing this issue.

A Critical Analysis of the American Nurses Association Position Statement on Workplace Violence: Ethical Implications.

In 2015, the American Nurses Association issued a position statement on workplace violence. An authoritative, disciplinary position is critically important to inform policies and recommendations addressing this significant issue in nursing. Position statements and policies should reflect disciplinary values. A discourse analysis of this position statement was performed through the lens of nursing ethics. The position statement endorses a zero-tolerance response, which is moralist, punitive, and questionably effective. It problematically presents patient and coworker violence as equivalent. Promotion of this position has the potential to erode public trust and lead us down a path of criminalizing illness behaviors.

Brief Workplace Interventions Addressing Burnout, Compassion Fatigue, and Teamwork: A Pilot Study.

Burnout and compassion fatigue are problematic for nurses, patients, and organizations. Identifying brief interventions nurses can engage in while at work to address compassion fatigue, burnout, and teamwork, as burnout and teamwork are inversely related, is important for all stakeholders. This quasi-experimental pilot study sought to examine the feasibility, acceptability, and effectiveness of five-minute interventions on nurses' burnout, compassion fatigue, and perceptions of teamwork. Nurses were randomized into five groups: meditation, journaling, gratitude, outside, and control. Participants engaged in the interventions, the majority of shifts worked, and many expressed a desire to continue after the six-week intervention period. Cohen's d effect sizes were greatest for burnout, range 0.495-0.757, and situation monitoring, range 0.252-1.1. The journaling group had the highest burnout (-11.88%), compassion satisfaction (7.54%), situation monitoring (-21.21%), and communication (-26.47%) Delta scores. Feasibility, acceptability, and effectiveness of these brief workplace interventions were preliminarily established to inform a larger study.

Nurses' participation in the Holocaust: A call to nursing educators.

This year marks the 75th anniversary of the liberation of Auschwitz. The number of people able to provide first-person accounts of the atrocities of the Holocaust is dwindling in numbers. Prior to the mass extermination of Jews at Auschwitz and other extermination camps, nurses actively participated in the execution of tens of thousands of mentally, physically, and emotionally ill German citizens. Nursing educators must ensure that nursing students not only know about the Holocaust, but that they know that ordinary nurses were directly involved in the identification of vulnerable humans to be killed, and actually murdered them. Social, economic, and political pressures existed enabling the Nazi regime to involve nurses in this way. Similarly, social, economic, and political pressures today have the potential to encourage nurses to act in ways that violate personal or professional values. This paper provides four learning objectives that can be incorporated into existing nursing curricula to ensure that nurses do not forget how and why nurses in Germany came to murder more than 10,000 people in their care. With the passage of time comes the risk that the legacy of the Holocaust will be forgotten, nursing educators must participate in preventing that from happening.

Paying for nursing student clinical placements, ethical considerations.

Ethics is foundational to nursing practice, including the practice of nursing education. Many schools of nursing are struggling to find adequate clinical placements for students; the root causes of this shortage are complex. Although it has not historically been the practice, some schools of nursing are considering offering clinical agencies payment for this valuable resource. Given the importance of clinical experience in nursing education, relationships between schools of nursing and clinical agencies are crucial. This paper explores some of the advantages and disadvantages that may present if schools of nursing pay clinical agencies to host nursing students, specifically pre-licensure students. Prior to establishing such relationships, schools of nursing and clinical agencies should carefully consider this decision. Questions informed by the American Nurses Association Code of Ethics and the National League for Nursing Ethical Principles for Nursing Education are provided as examples.

Drug-seeking: A literature review (and an exemplar of stigmatization in nursing).

Despite its lack of conceptual clarity and uniform definition, the term drug-seeking is used frequently by nurses from a variety of practice environments. The drugs patients are referred to as seeking are often pain medications. This is important because nursing has widely adopted a patient-centric definition of pain. Nursing also has a robust ethical code that places high value on human dignity and nurses' role in patient advocacy. A review of literature was conducted with the aims of describing whether/how the term drug-seeking has changed over time and to determine whether the use of the term in nursing literature is consistent with nursing values. Use of the term has shifted from objective counts of patient requests for medication to a confusing mixture of observable patient behavior and subjective interpretations of patient motivation. Its use is not consistent with nursing values. It is, in fact, a good illustration of stigmatization in nursing. Stigmatization is contrary to nursing values. Nurses in practice, research, education, authors, reviewers, and editors all have a role in ending this stigmatization.

Moral Ecology in Nursing: A Pluralistic Approach.

Moral dilemmas are present in all settings in which nurses work. Nurses are moral agents who must make moral decisions and take moral action in very complex social systems. Nurses are accountable for their actions, and it is therefore imperative that they have a solid foundation in ethics. There are multiple ethical frameworks nurses can utilize to justify their actions. A theory of moral ecology is presented here as a way to conceptualize the relationships between these frameworks. The first two steps of moral action, moral sensitivity and moral judgment, are explored in a pluralistic context. Specifically, multiple ethical frameworks that inform the practice of nursing are presented using an ecological model. Nurses work in a variety of practice environments, with different populations, across a spectrum of situations. An ecological model acknowledges that nurses are influenced by the complex social, and ethical, systems in which they find themselves taking moral action. When faced with ethical issues in practice, a nurse's moral sensitivity and moral judgment may be guided by ethical systems most proximal to the situation. Nurses bring individual moral beliefs to work and are influenced by the ethical directives of employers, the discipline's code of ethics, principles of bioethics, and various approaches to normative ethics (virtue, consequential, deontological, and care). Any of the frameworks presented may justifiably be applied in various nursing circumstances. I propose that the multiple ethical frameworks nurses utilize exist in a relationally nested manner and a model of moral ecology in nursing is provided.

The relationship between workplace violence, perceptions of safety, and Professional Quality of Life among emergency department staff members in a Level 1 Trauma Centre.

BACKGROUND: Emergency department staff members are frequently exposed to workplace violence which may have physical, psychological, and workforce related consequences. The purpose of this study was to examine the relationships between exposure to workplace violence, tolerance to violence, expectations of violence, perceptions of workplace safety, and Professional Quality of Life (compassion satisfaction - CS, burnout - BO, secondary traumatic stress - STS) among emergency department staff members. METHODS: A cross-sectional design was used to survey all emergency department staff members from a suburban Level 1 Trauma Centre in the western United States. RESULTS: All three dimensions of Professional Quality of Life were associated with exposure to non-physical patient violence including: general threats (CS p = .012, BO p = .001, STS p = .035), name calling (CS p = .041, BO p = .021, STS p = .018), and threats of lawsuit (CS p = .001, BO p = .001, STS p = .02). Tolerance to violence was associated with BO (p = .004) and CS (p = .001); perception of safety was associated with BO (p = .018). CONCLUSION: Exposure to non-physical workplace violence can significantly impact staff members' compassion satisfaction, burnout and secondary traumatic stress. Greater attention should be paid to the effect of non-physical workplace violence. Additionally, addressing tolerance to violence and perceptions of safety in the workplace may impact Professional Quality of Life.

Workplace Violence and Perceptions of Safety Among Emergency Department Staff Members: Experiences, Expectations, Tolerance, Reporting, and Recommendations.

Workplace violence (WPV) is a widely recognized problem in emergency departments (EDs). The majority of WPV studies do not include nonclinical staff and do not address expectations of violence, tolerance to violence, or perceptions of safety. Among a multidisciplinary sample of ED staff members, specific study aims were to (a) describe exposure to WPV; (b) describe perceptions of safety, tolerance to violence, and expectation of violence; (c) describe reporting behaviors and perceived barriers to reporting violence; (d) examine relationships between demographic variables, experiences of violence, tolerance to violence, perceptions of safety, and reporting behaviors; and (e) identify perceptions of viable interventions to improve workplace safety. A cross-sectional design was used to survey ED staff members in a Level 1 Shock Trauma center. Eleven disciplines were represented in 147 completed surveys; 88% of respondents reported exposure to WPV in the previous 6 months. Members of every discipline reported exposure to WPV; 98% of the sample felt safe at work and 64% felt violence was an expected part of the job. Most violence was not reported, primarily because "nobody was hurt." Emergency department staff members expected and experienced violence; nevertheless, there was a widespread perception of safety. Perceptions of safety and reasons for not reporting did not mirror previous findings. The WPV exposure is not isolated to clinical staff members and occurs even when prevention strategies are in place. The definition of WPV and the individual's interpretation of the event might preclude reporting.

Effects of Unit Design on Acute Care Nurses' Walking Distances, Energy Expenditure, and Job Satisfaction: A Pre-Post Relocation Study.

OBJECTIVES: The purpose of this study was to determine what differences occurred in steps taken and energy expenditure among acute care nurses when their work environment moved from a hospital with centralized nurses' stations to a hospital with decentralized nurses' stations. Additional goals were to determine design features nurses perceived as contributing to or deterring from their work activities and what changes occurred in reported job satisfaction. Since design features can also affect patient outcomes, patient falls were monitored. BACKGROUND: The construction of a replacement facility for a 224-bed Level 1 trauma center provided the opportunity to compare the effects of centralized versus decentralized nurses' stations on nurses' experiences of their work environments. METHOD: A pre-post quasi-experimental design was used. RN participants completed an open-ended questionnaire and recorded pedometer data at the end of each shift, working for 3-month pre-relocation and for 3-month post-relocation. Nine months passed between the move and post-relocation data collection. RESULTS: There were significant reductions in nurses' energy expenditure ( p < .001) and steps taken ( p = .041) post-relocation. Overall, nurses' job satisfaction was high and improved post-relocation, and patient falls decreased by 55%. CONCLUSIONS: Post-relocation, a number of the dissatisfiers associated with the physical environment were eliminated, and nurses identified more satisfiers (in general and related to the physical environment). Patients are safer post-relocation as indicated by a decrease in falls. This decrease is even more noteworthy when considering that the numbers of patient beds on each unit is higher post-relocation.