Development and validation of the Moral Distress in Dementia Care Survey instrument.

AIMS: To report on the development and validation of the Moral Distress in Dementia Care Survey instrument. BACKGROUND: Despite growing awareness of moral distress among nurses, little is known about the moral distress experiences of nursing staff in dementia care settings. To address this gap, our research team developed a tool for measuring the frequency, severity and effects of moral distress in nursing staff working in dementia care. DESIGN: The research team employed an exploratory sequential mixed method design to generate items for the moral distress questionnaire. Data were collected between January 2013 - June 2014. In this paper, we report on the development and validation of the Moral Distress in Dementia Care Survey instrument. METHODS: The Moral Distress in Dementia Care Survey instrument was piloted with a portion of the target population prior to a broader implementation. Appropriate statistical analyses and psychometric testing were completed. RESULTS: The team collected 389 completed surveys from registered nurses, licensed practical nurses and healthcare aides, representing a 43.6% response rate across 23 sites. The Moral Distress in Dementia Care Survey emerged as a reliable and valid instrument to measure the frequency, severity and effects of moral distress for nursing staff in dementia care settings. The relative value of the Moral Distress in Dementia Care Survey as a measurement instrument was superseded by its clinical relevance for dementia care staff. CONCLUSION: The Moral Distress in Dementia Care Survey is a potentially useful tool for estimating the frequency, severity and effects of moral distress in nursing staff working in dementia care settings and for the evaluation of measures taken to mitigate moral distress.

Caring in the wake of the rising tide: Moral distress in residential nursing care of people living with dementia.

Objective Moral distress is increasingly being recognized as a concern for health care professionals. The purpose of this study was to explore the nature and prevalence of moral distress among nursing staff who care for people living with dementia. Methods This study was focused on nursing staff caring for people with dementia in long-term care and assisted living sites. The Moral Distress in Dementia Care Survey instrument was distributed to 23 sites and nursing staff rated the frequency and severity of situations that were identified as potentially causing moral distress. Results Moral distress is prevalent in the nursing staff who provide dementia care. Nursing staff reported experiencing moral distress at least daily or weekly. Both frequency and severity of moral distress increased with proximity to (amount of time spent at) the bedside. Moral distress had negative psychological and physiological effects on nursing staff, and affected intention to quit.

Sources of moral distress for nursing staff providing care to residents with dementia.

The World Health Organization estimates the number of people living with dementia at approximately 35.6 million; they project a doubling of this number by 2030 and tripling by 2050. Although the majority of people living with a dementia live in the community, residential facility care by nursing care providers is a significant component of the dementia journey in most countries. Research has also shown that caring for persons with dementia can be emotionally, physically, and ethically challenging, and that turnover in nursing staff in residential care settings tends to be high. Moral distress has been explored in a variety of settings where nurses provide acute or intensive care. The concept, however, has not previously been explored in residential facility care settings, particularly as related to the care of persons with dementia. In this paper, we explore moral distress in these settings, using Nathaniel's definition of moral distress: the pain or anguish affecting the mind, body, or relationships in response to a situation in which the person is aware of a moral problem, acknowledges moral responsibility, makes a moral judgment about the correct action and yet, as a result of real or perceived constraints, cannot do what is thought to be right. We report findings from a qualitative study of moral distress in a single health region in a Canadian province. Our aim in this paper is to share findings that elucidate the sources of moral distress experienced by nursing care providers in the residential care of people living with dementia.

Elevated Hospitalization Risk of Assisted Living Residents With Dementia in Alberta, Canada.

OBJECTIVES: Assisted living (AL) is an increasingly used residential option for older adults with dementia; however, lower staffing rates and service availability raise concerns that such residents may be at increased risk for adverse outcomes. Our objectives were to determine the incidence of hospitalization over 1 year for dementia residents of designated AL (DAL) facilities, compared with long-term care (LTC) facilities, and identify resident- and facility-level predictors of hospitalization among DAL residents. METHODS: Participants were 609 DAL (mean age 85.7 ± 6.6 years) and 691 LTC (86.4 ± 6.9 years) residents with dementia enrolled in the Alberta Continuing Care Epidemiological Studies. Research nurses completed a standardized comprehensive assessment of residents and interviewed family caregivers at baseline (2006-2008) and 1 year later. Standardized administrator interviews provided facility level data. Hospitalization was determined via linkage with the provincial Inpatient Discharge Abstract Database. Multivariable Cox proportional hazards models were used to identify predictors of hospitalization. RESULTS: The cumulative annual incidence of hospitalization was 38.6% (34.5%-42.7%) for DAL and 10.3% (8.0%-12.6%) for LTC residents with dementia. A significantly increased risk for hospitalization was observed for DAL residents aged 90+ years, with poor social relationships, less severe cognitive impairment, greater health instability, fatigue, high medication use (11+ medications), and 2+ hospitalizations in the preceding year. Residents from DAL facilities with a smaller number of spaces, no chain affiliation, and from specific health regions showed a higher risk of hospitalization. CONCLUSIONS: DAL residents with dementia had a hospitalization rate almost 4-fold higher than LTC residents with dementia. Our findings raise questions about the ability of some AL facilities to adequately address the needs of cognitively impaired residents and highlight potential clinical, social, and policy areas for targeted interventions to reduce hospitalization risk.

A guest in the house: nursing instructors' experiences of the moral distress felt by students during inpatient psychiatric clinical rotations.

Significant research has been done on the impact of moral distress among nurses, particularly in acute and intensive care settings. However, little research to date has investigated the experiences that nursing students have with moral distress. Additionally, there is a dearth of research on the role of nursing instructors' perceptions of their responsibilities to their students when encountering morally distressing situations. This manuscript describes a qualitative study conducted with eight mental health nursing instructors who acknowledged a responsibility for helping students deal with moral distress and ethical issues, but who also struggled with ways to do so. Additionally, instructors expressed frustration with their "guest" status on inpatient psychiatric units and their powerlessness to effect moral change in a medical model of psychiatric care.

High rates of hospital admission among older residents in assisted living facilities: opportunities for intervention and impact on acute care.

BACKGROUND: Little is known about health or service use outcomes for residents of Canadian assisted living facilities. Our objectives were to estimate the incidence of admission to hospital over 1 year for residents of designated (i.e., publicly funded) assisted living (DAL) facilities in Alberta, to compare this rate with the rate among residents of long-term care facilities, and to identify individual and facility predictors of hospital admission for DAL residents. METHODS: Participants were 1066 DAL residents (mean age ± standard deviation 84.9 ± 7.3 years) and 976 longterm care residents (85.4 ± 7.6 years) from the Alberta Continuing Care Epidemiological Studies (ACCES). Research nurses completed a standardized comprehensive assessment for each resident and interviewed family caregivers at baseline (2006 to 2008) and 1 year later. We used standardized interviews with administrators to generate facility- level data. We determined hospital admissions through linkage with the Alberta Inpatient Discharge Abstract Database. We used multivariable Cox proportional hazards models to identify predictors of hospital admission. RESULTS: The cumulative annual incidence of hospital admission was 38.9% (95% confidence interval [CI] 35.9%- 41.9%) for DAL residents and 13.7% (95% CI 11.5%-15.8%) for long-term care residents. The risk of hospital admission was significantly greater for DAL residents with greater health instability, fatigue, medication use (11 or more medications), and 2 or more hospital admissions in the preceding year. The risk of hospital admission was also significantly higher for residents from DAL facilities with a smaller number of spaces, no licensed practical and/ or registered nurses on site (or on site less than 24 hours a day, 7 days a week), no chain affiliation, and from select health regions. INTERPRETATION: The incidence of hospital admission was about 3 times higher among DAL residents than among long-term care residents, and the risk of hospital admission was associated with a number of potentially modifiable factors. These findings raise questions about the complement of services and staffing required within assisted living facilities and the potential impact on acute care of the shift from long-term care to assisted living for the facility-based care of vulnerable older people.

I was told it restarts your brain: knowledge, power, and women's experiences of ECT.

BACKGROUND: A discrepancy exists between clinician-led studies of people's experience of electroconvulsive therapy (ECT) and consumer-led studies, with the former typically being much more positive about the efficacy and side effects of ECT compared with the latter. Qualitative in-depth explorations of people's experiences of ECT are relatively rare, particularly those looking specifically at women's experience of ECT. AIMS: The aim of this qualitative study was to explore women's experiences of ECT, particularly their experience of knowledge and power related to ECT. RESULTS: Qualitative analysis of the interviews with nine women resulted in four main themes emerging from the interviews with the women: (i) "he really didn't say much," (ii) "I'm going to be very upset with you," (iii) "I was just desperate," and (iv) "it was like we were cattle." CONCLUSIONS: Overall, participants found their experiences with ECT to be quite negative, and characterized by a lack of knowledge during the procedure, and a lack of power throughout the entire process.

No place to turn: nursing students' experiences of moral distress in mental health settings.

While researchers have documented the significant issue of moral distress among nurses, few have explored moral distress among mental health nurses. In addition, no research to date has explored nursing students' experiences of moral distress during mental health clinical rotations, despite nursing students typically reporting negative attitudes towards mental health nursing. This manuscript reports on a qualitative study involving seven Canadian baccalaureate nursing students, who reported on their experiences of moral distress during a 13-week clinical rotation on inpatient psychiatric units. Overall, nursing students reported significant moral distress related to the perceived lack of nurses talking meaningfully to patients on the unit, a hierarchical power structure for physicians, a lack of information given to patients about their psychiatric medications, and an inability of their nursing instructors to advocate for ethical change on the units. Several students made a specific connection between their moral distress and not wanting to pursue a career in mental health nursing.

Predictors of Nursing Home Placement from Assisted Living Settings in Canada.

We sought to estimate the incidence of long-term care (LTC) placement and to identify resident- and facility-level predictors of placement among older residents of designated assisted living (AL) facilities in Alberta, Canada. Included were 1,086 AL residents from 59 facilities. Research nurses completed interRAI-AL resident assessments and interviewed family caregivers and administrators. Predictors of placement were identified with multivariable Cox proportional hazards models. The cumulative incidence of LTC admission was 18.3 per cent by 12 months. Significantly increased risk for placement was evident for older residents and those with poor social relationships, little involvement in activities, cognitive and/or functional impairment, health instability, recent falls and hospitalizations/emergency department visits, and severe bladder incontinence. Residents from larger facilities, with an LPN and/or RN on-site 24/7 and with an affiliated primary care physician, showed lower risk of placement. Our findings highlight clinical and policy areas where targeted interventions may delay LTC admissions.

All I have is a void: women's perceptions of the benefits and side effects of ECT.

BACKGROUND: Recent reviews of the benefits and risks associated with electroconvulsive therapy (ECT) have often reported mixed and conflicting results. Although there are very few qualitative studies on ECT, qualitative research offers the advantage of in-depth explorations into how people perceive and experience ECT. OBJECTIVE: The objective of this qualitative study was to explore women's experiences and perceptions of the benefits and side effects associated with having ECT. METHODS: The authors used narrative inquiry and in-depth interviews to obtain nine women's accounts and stories of ECT, focusing particularly on their accounts of perceived benefits and side effects associated with ECT. RESULTS: Qualitative thematic analysis of the interviews with nine women resulted in four main themes emerging from the interviews: "it's sort of like housecleaning," "I don't remember the wedding," made me stupider," and "putting them in a cage with a bear." CONCLUSIONS: Three of the women were able to articulate some perceived benefit arising from ECT, although these women also acknowledged the benefits did not last more than two weeks. The majority of women complained of significant and persistent autobiographical memory loss, cognitive deficits, and fear of the procedure.

Fear and loathing: undergraduate nursing students' experiences of a mandatory course in applied statistics.

This article describes the results of a qualitative research study evaluating nursing students' experiences of a mandatory course in applied statistics, and the perceived effectiveness of teaching methods implemented during the course. Fifteen nursing students in the third year of a four-year baccalaureate program in nursing participated in focus groups before and after taking the mandatory course in statistics. The interviews were transcribed and analyzed using content analysis to reveal four major themes: (i) "one of those courses you throw out?," (ii) "numbers and terrifying equations," (iii) "first aid for statistics casualties," and (iv) "re-thinking curriculum." Overall, the data revealed that although nursing students initially enter statistics courses with considerable skepticism, fear, and anxiety, there are a number of concrete actions statistics instructors can take to reduce student fear and increase the perceived relevance of courses in statistics.

Evaluation of undergraduate nursing students' attitudes towards statistics courses, before and after a course in applied statistics.

BACKGROUND: Undergraduate nursing students must often take a course in statistics, yet there is scant research to inform teaching pedagogy. OBJECTIVES: The objectives of this study were to assess nursing students' overall attitudes towards statistics courses - including (among other things) overall fear and anxiety, preferred learning and teaching styles, and the perceived utility and benefit of taking a statistics course - before and after taking a mandatory course in applied statistics. DESIGN AND METHOD: The authors used a pre-experimental research design (a one-group pre-test/post-test research design), by administering a survey to nursing students at the beginning and end of the course. SETTING: The study was conducted at a University in Western Canada that offers an undergraduate Bachelor of Nursing degree. PARTICIPANTS: Participants included 104 nursing students, in the third year of a four-year nursing program, taking a course in statistics. RESULTS: Although students only reported moderate anxiety towards statistics, student anxiety about statistics had dropped by approximately 40% by the end of the course. Students also reported a considerable and positive change in their attitudes towards learning in groups by the end of the course, a potential reflection of the team-based learning that was used. Students identified preferred learning and teaching approaches, including the use of real-life examples, visual teaching aids, clear explanations, timely feedback, and a well-paced course. Students also identified preferred instructor characteristics, such as patience, approachability, in-depth knowledge of statistics, and a sense of humor. Unfortunately, students only indicated moderate agreement with the idea that statistics would be useful and relevant to their careers, even by the end of the course. CONCLUSIONS: Our findings validate anecdotal reports on statistics teaching pedagogy, although more research is clearly needed, particularly on how to increase students' perceptions of the benefit and utility of statistics courses for their nursing careers.

Towards culturally relevant nursing education for aboriginal students.

Aboriginal nursing students face numerous challenges in North American nursing educational programs, as reflected in the relatively high attrition rate of these students. In this paper, the authors argue that nurse educators need to create more culturally relevant curriculum and instructional approaches for Aboriginal students. Such approaches would help nursing educators to ensure that current aboriginal nursing programs--which are largely assimilative in nature--can be more successful and transformative in nature.

Interpersonal boundaries in clinical nursing education: An exploratory Canadian qualitative study.

BACKGROUND: Clinical nursing instructors and students spend considerable time together, and share clinical experiences that can be intense and emotionally charged. Yet despite clinical teaching being so commonplace, little is known about how clinical instructors experience relationships with their students, and how they negotiate interpersonal boundaries within these relationships. METHODS: In-depth unstructured interviews were conducted with eight clinical nursing instructors in Western Canada, to explore how they defined and constructed interpersonal boundaries with their students during clinical nursing teaching rotations. RESULTS: The data analysis resulted in four major themes: "the fluidity of boundaries", "personal sharing and self-disclosure", "time dependent", and "the touchy topic of touch". All participants agreed that rigid boundaries were occasionally needed to prevent flagrant boundary violations, such as sexual relations with students. However, participants also stated that overall, the unique and complex nature of clinical teaching called for instructors to have fluid and flexible interpersonal boundaries with students. IMPLICATIONS: The nature of clinical nursing education may encourage instructors to form relationships with their students that are characterized by flexible and fluid interpersonal boundaries. Clinical nursing instructors may benefit from opportunities to dialogue with trusted colleagues about the unique nature of relationships and boundaries with students during clinical teaching.

Lets Do Lunch? The ethics of accepting gifts from the pharmaceutical industry.

When nurses think of ethical issues, debates on assisted suicide or maternal versus fetal rights often come to mind. A less obvious but undoubtedly more common ethical issue is whether or not sponsored lunches, educational events and other forms of gift giving should be accepted from pharmaceutical companies. The authors review the nature of pharmaceutical marketing and gift giving and examine some of the potential ethical issues that arise when nurses accept these gifts.

Impact of exercise on seniors' motor control response to external dynamics.

Research on postural stability, motor control, and fall occurrence in seniors is common, but few studies address the influence of exercise and external dynamics on elderly balance. Using pre- and post-training tests, the effects of a Fitball exercise program on performance in eight subjects was documented. The exercise program focused on improving dynamic balance and postural stability of seniors. To evaluate progress-related changes, pre- and post-tests in a dynamic environment were applied. Center of gravity (COG) excursion, catch success rate, and balance success rate were quantified, and synchronized data collection of 3D motion capture (VICON v8i) and ground reaction force (2 KISTLER platforms) was analyzed. During pre- and post-tests, participants stood in a walklike stance and were asked to catch a weighted ball, which dropped unexpectedly. Results showed no significant changes in balance success rate. Significant improvements were found, however, in both COG control and catch success rate following training (p<0.05).

Measuring melancholy: a critique of the Beck Depression Inventory and its use in mental health nursing.

The Beck Depression Inventory (BDI) is one of the most commonly used depression measurement instruments. Mental health nurses often utilize the BDI to assess the level of depression in clients, and to monitor the effectiveness of treatments such as antidepressants and electroconvulsive therapy. Despite the widespread use of the BDI in both clinical practice and research, there is surprisingly little nursing literature critically examining the BDI or its use by mental health nurses. This paper reviews the origins, purpose, and format of the BDI, discusses some of the strengths and limitations of the BDI, and concludes with some implications for mental health nursing.

Innovations in the Ethical Review of Health-Related Quality Improvement and Research: The Alberta Research Ethics Community Consensus Initiative (ARECCI).

The Alberta Research Ethics Community Consensus Initiative (ARECCI) is a unique Canadian initiative that addresses the ethical oversight of two main categories of health-related investigative projects: research and quality improvement (including quality assurance and program evaluation). ARECCI was formed as a result of discussions arising from health regions, health researchers and the Alberta Committee of Research Ethics Boards (REBs) Chairs, who all desired a clearer and more consistent approach to the ethical oversight of investigative health projects. The Alberta Heritage Foundation for Medical Research (AHFMR) established and supported ARECCI in 2003 in response to this need. ARECCI is unique in its ongoing efforts to bring together a wide-ranging group of stakeholders to develop consensus on a set of pragmatic recommendations and tools for the ethical review of research and quality improvement, and to get extensive consultation on those recommendations. This paper presents the ARECCI context and process, recommendations and tools produced by ARECCI and lessons learned from the ongoing ARECCI process.

Use of major and minor tranquilizers with older patients in an acute care hospital: an exploratory study.

AIM: This paper reports a study to determine how many older patients are prescribed major and/or minor tranquilizers during their hospital stay, and the perceptions of acute care nursing staff towards the use of such medications with older hospitalized patients. BACKGROUND: While considerable research exists on the use of major and minor tranquilizers (chemical restraints) with older people in long-term care, scant research has addressed the use of these drugs with older patients in acute care hospitals. Given the growing numbers of older people with dementia and delirium in hospitals, and the risks these drugs pose to older people, more research on the use of chemical restraints by nurses with older hospital patients is needed. METHODS: Computerized pharmacy records were used to access data on prescriptions of major and minor tranquilizers to older patients during one month on six hospital units (total n = 498), and 140 nursing staff from these units completed the Perceptions of (Chemical) Restraint Use Questionnaire. The data were collected in 2003. RESULTS: A minority of older patients (8.63%) were prescribed a major or minor tranquilizer during the one-month data collection period. The numbers prescribed minor tranquilizers (6.22%, n = 31) were approximately double that of major tranquilizers (3.21%, n = 16). The majority of prescriptions for minor and major tranquilizers were written as pro re nata or 'as needed' (77% and 55.8%, respectively). Nurses' scores on the Perceptions of (Chemical) Restraint Use Questionnaire indicated perceptions consistent with liberal use of chemical restraints, and several of the highly rated reasons for giving such medications could be considered inappropriate. CONCLUSIONS: While these findings suggest that only a small number of older people were prescribed chemical restraint medications in hospital, the risks these medications pose warrants ongoing prudence. More nursing research and education on the use of these medications with older people in hospital settings is needed.

A new role for advanced practice nurses in Canada: bridging the gap in health services for rural older adults.

This article is a report on the evaluation of a new nursing initiative in rural western Canada-the gerontological advanced practice nurse (GAPN) project. Using a qualitative approach in the i initial evaluative phase, the authors determined how the GAPN evolved, functioning primarily in a clinical nurse specialist role, and identified the successes and challenges of the project. The initial findings indicated health benefits to rural older adults. The project's success was attributed to strong support from key players, and attempts to address perceived gaps in rural health service. Challenges in developing the GAPN role included limited planning time, and lack of a clear definition about the role and responsibilities of the GAPN. The introduction of a GAPN, especially in underserved rural communities, has the potential to provide essential health care services to older adults, and to make major contributions to changing gerontology practice.