Everyday Clinical Ethics: Essential Skills and Educational Case Scenarios.

Bioethics conjures images of dramatic healthcare challenges, yet everyday clinical ethics issues unfold regularly. Without sufficient ethical awareness and a relevant working skillset, clinicians can feel ill-equipped to respond to the ethical dimensions of everyday care. Bioethicists were interviewed to identify the essential skills associated with everyday clinical ethics and to identify educational case scenarios to illustrate everyday clinical ethics. Individual, semi-structured interviews were conducted with a convenience sample of bioethicists. Bioethicists were asked: (1) What are the essential skills required for everyday clinical ethics? And (2) What are potential educational case scenarios to illustrate and teach everyday clinical ethics? Participant interviews were analyzed using qualitative content analysis. Twenty-five (25) bioethicists completed interviews (64% female; mean 14.76 years bioethics experience; 80% white). Five categories of general skills and three categories of ethics-specific skills essential for everyday clinical ethics were identified. General skills included: (1) Awareness of Core Values and Self-Reflective Capacity; (2) Perspective-Taking and Empathic Presence; (3) Communication and Relational Skills; (4) Cultural Humility and Respect; and (5) Organizational Understanding and Know-How. Ethics-specific skills included: (1) Ethical Awareness; (2) Ethical Knowledge and Literacy; and (3) Ethical Analysis and Interaction. Collectively, these skills comprise a Toolbox of Everyday Clinical Ethics Skills. Educational case scenarios were identified to promote everyday ethics. Bioethicists identified skills essential to everyday clinical ethics. Educational case scenarios were identified for the purpose of promoting proficiency in this domain. Future research could explore the impact of integrating educational case scenarios on clinicians' ethical competencies.

Psychometric validation of the Persian version of the ethical awareness scale for nurses working in Iranian intensive care units.

AIM: The purpose of this study was to translate and validate the ethical awareness scale for nurses working in Iranian intensive care units. DESIGN: A cross-sectional psychometric study. METHODS: The study was conducted in Oct 2020 to Sep 2021, involving the participation of 200 ICU nurses. The process included translation of the original version of the ethical awareness scale into Persian, following the World Health Organization guideline, for use in Iran. The translated version was then evaluated for reliability, face validity, content validity ratio, content validity index, convergent validity and construct validity. RESULTS: The initial reliability of the scale was established. In qualitative face validity, a few items changed slightly and all items were retained in the quantitative face validity assessment. Based on Lawshe's values, three items were removed from the scale during CVR assessment. All items exhibited acceptable CVI scores. Convergent validity was established with an average variance extracted greater than 0.5. The fit indices, such as CFI = 0.94, GFI = 0.94, RMSEA = 0.01, AGFI = 0.97 and CMIN/DF = 2.99, supported the structural model of the scale. The fit indices for the structural model of the scale were all within acceptable ranges, suggesting that the model fit the data well. Its reliability was confirmed through the test-retest method, with Cronbach's alpha = 0.84 and McDonald's omega coefficient >0.8. CONCLUSION: The findings of this study indicate the Persian version of the ethical awareness scale for Iran (EAS-IR) is comparable in content to the original version, demonstrating its validity and reliability for assessing ethical awareness among Iranian nurses in ICUs. The scale can be a valuable resource for measuring ethical awareness in the Iranian healthcare context and may contribute to improving ethical practices and decision-making in ICU settings. PATIENT OR PUBLIC CONTRIBUTION: In this project, no patient or public contribution was necessary, because it was not applied to our work.

Nursing vaccine mandates: Ethically justified, an infringement on autonomy, or both?

After almost a year and a half of the COVID-19 pandemic, many healthcare institutions in the United States announced that they would mandate COVID-19 vaccination, with medical and religious exceptions, as a term of employment. The mandates resulted in widely publicized protests from hospital staff, including some nurses, who argued that these medical institutions violated the ethical principle of autonomy. As the world enters the "post-pandemic period," decisions such as these, made during times of crisis, must be reviewed to provide clarity for when the next pandemic occurs. In this paper, we support the argument that such mandates are ethically justifiable. We explore the framework of objections that were brought forward by dissenters of this vaccine mandate. Next, we provide an analysis of conflicting ethical principles present when such mandates were deployed. Utilizing the American Nurses Association's Code of Ethics for Nurses, notably provisions 2, 3, and 6 we argue that it is an ethical duty of the nurse to be vaccinated. Specifically, we turn to provision two, which most explicitly underscores the necessity of vaccination as a function of the nurse's primary commitment to the patient. Next, we highlight the International Council of Nurses Code of Ethics which provides similar guidance internationally. Finally, we examine the applicability of the principles of public health, care ethics, and the nursing role as frameworks to underpin such mandates both for the current and for potential future pandemics, arguing that the nurse's ethical duty to be vaccinated spans these contexts.

Advocacy and Bioethics: Aspiration, Obligation, and Negotiation.

AbstractA long-standing tenet of healthcare clinical ethics consultation has involved the neutrality of the ethicist. However, recent pressing societal issues have challenged this viewpoint. Perhaps now more than ever before, ethicists are being called upon to take up roles in public health, policy, and other community-oriented endeavors. In this article, I first review the concept of professional advocacy and contrast this conceptualization with the role of patient advocate, utilizing the profession of nursing as an exemplar. Then, I explore the status of advocacy in clinical ethics and how this conversation intersects with the existing professional obligations of the bioethicist, arguing that the goals of ethics consultation and ethical obligations of the clinical ethicist are compatible with the role of professional advocate. Finally, I explore potential barriers to professional advocacy and offer suggestions for a path forward.

The Psychoneuroimmunological Model of Moral Distress and Health in Healthcare Workers: Toward Individual and System-Level Solutions.

Healthcare is presently experiencing a global workforce crisis, marked by the inability of hospitals to retain qualified healthcare workers. Indeed, poor working conditions and staff shortages have contributed to structural collapse and placed a heavy toll on healthcare workers' (HCWs) well-being, with many suffering from stress, exhaustion, demoralization, and burnout. An additional factor driving qualified HCWs away is the repeated experience of moral distress, or the inability to act according to internally held moral values and perceived ethical obligations due to internal and external constraints. Despite general awareness of this crisis, we currently lack an organized understanding of how stress leads to poor health, wellbeing, and performance in healthcare workers. To address this critical issue, we first review the literature on moral distress, stress, and health in HCWs. Second, we summarize the biobehavioral pathways linking occupational and interpersonal stressors to health in this population, focusing on neuroendocrine, immune, genetic, and epigenetic processes. Third, we propose a novel Psychoneuroimmunological Model of Moral Distress and Health in HCWs based on this literature. Finally, we discuss evidence-based individual- and system-level interventions for preventing stress and promoting resilience at work. Throughout this review, we underscore that stress levels in HCWs are a major public health concern, and that a combination of system-level and individual-level interventions are necessary to address preventable health care harm and foster resilience in this population, including new health policies, mental health initiatives, and additional translational research.

A semantic exploration: Nurse ethicist, medical ethicist, or clinical ethicist: Do distinctions matter?

Since the 1960s, it has been recognized that "medical ethics," the area of inquiry about the obligations of practitioners of medicine, is inadequate for capturing and addressing the complexities associated with modern medicine, human health, and wellbeing. Subsequently, a new specialty emerged which involved scholars and professionals from a variety of disciplines who had an interest in healthcare ethics. The name adopted is variously biomedical ethics or bioethics. The practice of bioethics in clinical settings is clinical ethics and its primary aim is to resolve patient care issues and conflicts. Nurses are among these clinical ethicists. They are drawn to the study and practice of bioethics and its applications as way to address the problems encountered in practice. A significant number are among the ranks of clinical ethicists. However, in the role of bio- or clinical ethicist, some retained the title of their original profession, calling themselves nurse ethicists, and some did not. In this article, we explore under which conditions it is permissible or preferable that one retains one's prior profession's nomenclature as a prefix to "ethicist," under which conditions it is not, and why. We emphasize the need for transparency of purpose related to titles and their possible influence on individual and social good.

Performance of crisis standards of care guidelines in a cohort of critically ill COVID-19 patients in the United States.

Many US states published crisis standards of care (CSC) guidelines for allocating scarce critical care resources during the COVID-19 pandemic. However, the performance of these guidelines in maximizing their population benefit has not been well tested. In 2,272 adults with COVID-19 requiring mechanical ventilation drawn from the Study of the Treatment and Outcomes in Critically Ill Patients with COVID-19 (STOP-COVID) multicenter cohort, we test the following three approaches to CSC algorithms: Sequential Organ Failure Assessment (SOFA) scores grouped into ranges, SOFA score ranges plus comorbidities, and a hypothetical approach using raw SOFA scores not grouped into ranges. We find that area under receiver operating characteristic (AUROC) curves for all three algorithms demonstrate only modest discrimination for 28-day mortality. Adding comorbidity scoring modestly improves algorithm performance over SOFA scores alone. The algorithm incorporating comorbidities has modestly worse predictive performance for Black compared to white patients. CSC algorithms should be empirically examined to refine approaches to the allocation of scarce resources during pandemics and to avoid potential exacerbation of racial inequities.

Ethics Consultations at a Major Academic Medical Center: A Retrospective, Longitudinal Analysis.

BACKGROUND: Evidence suggests that healthcare professionals feel inadequately equipped to manage ethical issues that arise, resulting in ethics-related stress. Clinical ethics consultation, and preventive ethics strategies, have been described as ways to decrease ethics-related stress, however information is limited regarding specific sources of ethical concern. METHODS: The purpose of this study was to conduct a retrospective, longitudinal analysis of a comprehensive database of ethics consultations, at a major academic medical center in the Northeast United States in order to: (1) Discern major sources of ethical concern, (2) Evaluate how these have changed over time in their content and frequency, (2a) Evaluate trends in nurse versus physician-initiated requests. RESULTS: Six major reasons for requesting an ethics consult were identified: Conflict Over Goals of Care, Decisional Capacity, Withholding/Withdrawing Treatment, Proxy Decision Making, Communication, and Behavior. Themes were operationally defined by the study team. An increase in requests related to Conflict Over Goals of Care (ß = 0.7, 95% CI = 0.2-1.2, p = 0.008) and Discharge Planning (ß = 2.2, 95% CI = 1.4-3.1, p < 0.001), and a trend toward increased number of consults for behavior-related consults from nurses (median 6.5% versus 2.3%, p = 0.07) were noted. Nurses were significantly more likely than physicians to request ethics consultation for Communication (yearly median 10.4% of cases vs 1.3% of cases, p = 0.01), whereas, physicians were significantly more likely to request ethics consultation for Proxy Decision-Making than nurses (yearly median 26.0% of cases vs 13.0%, p = 0.005) and for Decision-Making Capacity (yearly median 7.5% of cases vs 4.0%, p = 0.04). CONCLUSIONS: This study revealed several noteworthy and previously unidentified trends in consultation requests, and several important distinctions between the sources of ethical concern nurses identify versus those physicians identify. These findings can be used to develop future preventive-ethics frameworks.

CE: Brain Death: History, Updates, and Implications for Nurses.

In 1968, the criteria for brain death were established by the Harvard Ad Hoc Committee. Despite what may appear to be unambiguous definitions, clinicians, ethicists, and the public have grappled with the concept of brain death since its inception. In light of recent public discourse on the topic, Harvard Medical School convened a conference to examine research and ethical inquiry conducted over the past 50 years related to death as defined by neurologic criteria. Drawing on the report produced by this conference, this article provides an overview of the development of brain death criteria, describes recent controversies and updates, and discusses implications of these criteria for nurses.

Ethical Awareness Scale: Replication Testing, Invariance Analysis, and Implications.

Background: Ethical awareness (EA) enables nurses to recognize the ethical implications of all practice actions and is an important component of safe and quality nursing care. Evidence suggests that nurses may sometimes feel underprepared to recognize and address ethical issues as they arise in practice. The Ethical Awareness Scale (EAS) presented strong evidence as a psychometrically sound measure of EA in critical care nurses in pilot testing. The present study extends earlier work by (a) expanding the sample, (b) replicating the psychometric analyses, (c) more deeply investigating data-to-model fit, and (d) providing guidelines for the interpretation of EAS scores and subsequent practice-focused and educational interventions. Methods: This study utilized two sets of cross-sectional EAS survey results with ICU nurse respondents from two hospitals in New England. Invariance testing using simple OLS regression was conducted between the item estimates of both samples. The final Rasch analysis utilized a rating scale model. Finally, a score interpretation framework was developed. Results: 240 participants were included in the combined analysis. Nurses were predominantly female (93.1%), aged 25-35 (39.9%), and Bachelor's degree prepared (73.4%). Mean levels of EA were in the low/moderate range (M = 36.2/54). Cronbach's alpha of 0.86 was achieved. The Rasch analysis demonstrated a variable map structure consistent with the hypothesized item order, scoring categories that were sufficiently used by respondents, and adequate model-data fit. Conclusions: This study demonstrates that the EAS is a psychometrically sound and meaningful measure of EA in critical care nurses with item difficulty estimates that are invariant across samples. A raw score on the EAS can be practically interpreted, given the theoretical description of what a nurse at each level of the scale's continuum may "look" like in terms of EA using the diagnostic interpretation table. These findings have implications for nursing education and practice.

"It's Changed Everything": Voices of Veterans in the Veteran-Directed Home and Community Based Services Program.

The purpose of this study was to understand the value and impact of the Veteran-Directed Home and Community Based Services program (VD-HCBS) on Veterans' lives in their own voices. Focus groups and individual interviews by telephone were conducted to elicit participant perspectives on what was most meaningful, and what difference VD-HCBS made in their lives. Transcripts were analyzed using content analysis. The sample included 21 Veterans, with a mean age of 66±14, enrolled in VD-HCBS an average of 20.8 months. All were at risk of institutional placement based on their level of disability. Five major categories captured the information provided by participants: What a Difference Choice Makes; I'm a Person!; It's a Home-Saver; Coming Back to Life; and Keeping Me Healthy & Safe. Participants described the program as life changing. This study is the first time that Veterans themselves have identified the ways in which VD-HCBS impacted their lives, uncovering the mechanisms underlying positive outcomes. These categories revealed new ways of understanding VD-HCBS as an innovative approach to meeting the person-centered needs of Veterans wishing to remain at home, while experiencing quality care and leading meaningful lives, areas identified as priorities for improving long term services and supports.

"I'm just trying to cope for both of us": Challenges and supports of family caregivers in participant-directed programs.

Recently, national attention has focused on the needs of family caregivers providing complex chronic care, noting the necessity to better understand the scope of challenges they encounter. Although a robust body of literature exists about the scope of family caregiving, little is known specifically about the experiences and perspectives of family caregivers who support participant directed (PD) participants, particularly across the caregiving trajectory. Therefore, the aim of this qualitative descriptive study was to describe what family caregivers of individuals with developmental disabilities, physical disabilities, aging, or chronic health conditions identify as the challenges they experience as complex, and their perceptions of the effectiveness and gaps in family support resources in PD. Semi-structured interviews were audio-recorded with a purposive sample of caregivers. Transcribed interviews were analyzed using conventional content analysis. Fifty-four caregivers of individuals with a range of disabilities participated (age 34-78, M 59.9 ± 8.8; male 19%; spouse 17%, parent 61%). Six categories emerged from the analysis: contextualizing complexity, complexity in transitions, coping with complexity: advocacy & isolation, supportive support, unsupportive support, and systems challenges. Caregivers emphasized the interplay between unpredictability, transitions, and complexity and the interaction between the person receiving support, the caregiver's own situation, and the environment. Findings highlight the need, and provide a guide, for family assessment and for tailoring interventions matched to the profiles and self-identified challenges of families living with disability. Social workers can learn what families see as complex and what support broker behaviors families find helpful, and which not.

When Societal Structural Issues Become Patient Problems: The Role of Clinical Ethics Consultation.

The debate about health insurance coverage and the related issue of unequal access to health care turn on fundamental questions of justice, but for an individual patient like DM, the abstract question about who is deserving of health insurance becomes a very concrete problem that has a profound impact on care and livelihood. DM's circumstances left him stuck in the hospital. A satisfactory discharge plan remained elusive; his insurance coverage severely limited the number and type of facilities that would accept him; and his inadequate engagement in his own rehabilitation process limited discharge options even further. Despite extensive involvement with the psychiatry, social work, physical therapy, and occupational therapy teams, DM consistently made "bad" decisions. He repeatedly refused antibiotics and did not consistently work with rehab services to improve his strength and mobility. Although the clinicians wanted to provide him with the best care possible, he often seemed unwilling to do the things necessary to achieve this care-or perhaps his depression rendered him unable to do so. He also tended to take out his frustration on staff members caring for him. All of this was, in turn, very frustrating for the staff. It may be easy, however, to make too much of DM's role, to see his choices as more important than his circumstances. A major goal of the ethics consultants was to reframe DM's predicament for the staff members involved in his care.

The development and psychometric validation of the Ethical Awareness Scale.

AIM: To develop and psychometrically assess the Ethical Awareness Scale using Rasch measurement principles and a Rasch item response theory model. BACKGROUND: Critical care nurses must be equipped to provide good (ethical) patient care. This requires ethical awareness, which involves recognizing the ethical implications of all nursing actions. Ethical awareness is imperative in successfully addressing patient needs. Evidence suggests that the ethical import of everyday issues may often go unnoticed by nurses in practice. Assessing nurses' ethical awareness is a necessary first step in preparing nurses to identify and manage ethical issues in the highly dynamic critical care environment. DESIGN: A cross-sectional design was used in two phases of instrument development. METHOD: Using Rasch principles, an item bank representing nursing actions was developed (33 items). Content validity testing was performed. Eighteen items were selected for face validity testing. Two rounds of operational testing were performed with critical care nurses in Boston between February-April 2017. RESULTS: A Rasch analysis suggests sufficient item invariance across samples and sufficient construct validity. The analysis further demonstrates a progression of items uniformly along a hierarchical continuum; items that match respondent ability levels; response categories that are sufficiently used; and adequate internal consistency. Mean ethical awareness scores were in the low/moderate range. CONCLUSION: The results suggest the Ethical Awareness Scale is a psychometrically sound, reliable and valid measure of ethical awareness in critical care nurses.

Refining moral agency: Insights from moral psychology and moral philosophy.

Research in moral psychology has recently raised questions about the impact of context and the environment on the way the human mind works. In a 2012 call to action, Paley wrote: "If some of the conclusions arrived at by moral psychologists are true, they are directly relevant to the way nurses think about moral problems, and present serious challenges to favoured concepts in nursing ethics, such as the ethics of care, virtue, and the unity of the person" (p. 80). He urges nurse ethicists and scholars to evaluate the impact these findings may have for moral theory. In this paper, I review some of Paley's (Nursing Philosophy, 13, 2012, 80) critique, focusing on the argument that theories of nursing ethics have failed to account for the role of context; both in terms of its impact on the way nurses make moral judgements and in terms of the environment's influence on the way the mind works. I then examine nursing literature on moral agency, and focus on the role of the environment and context play within existing theory. I argue that theories of moral agency have often accounted for the role of context on the way nurses make decisions; however, less attention has been paid to its impact on the mind. With this background, I use insights from the fields of moral philosophy and moral psychology to refine the conceptualization of nurse moral agency in a way that is reflective of current cognitive, philosophical and nursing practice-based science.