The Evolving Complexities of MAID Care in Canada From a Nursing Perspective.

Medical Assistance in Dying (MAID) legislation has evolved rapidly in Canada with significant impacts on nursing practice. The purpose of this paper is to describe evolving complexities in legislative context and practice standards that influence the experiences nurse practitioners and registered nurses have with MAID. Qualitative interviews were conducted with 25 registered nurses and 10 nurse practitioners from diverse contexts across Canada. Participants described their practices and considerations when discussing MAID as part of advance care planning; their use of, and challenges with, waivers of consent; their practice considerations in negotiating the complexities of clients for whom death is not reasonably foreseeable; and their moral wrestling with the inclusion of MAID for persons whose sole underlying medical condition is mental illness. Findings illustrate the moral complexities inherent in the evolving legislation and the importance of robust health and social care systems to the legal and ethical implementation of MAID in Canada.

Protecting the public interest while regulating health professionals providing virtual care: A scoping review.

Technology is transforming service delivery in many health professions, particularly with the rapid shift to virtual care during the COVID-19 pandemic. Health profession regulators must navigate legal and ethical complexities to facilitate virtual care while upholding their mandate to protect the public interest. The objectives of this scoping review were to examine how the public interest is protected when regulating health professionals who provide virtual care, discuss policy and practice implications of virtual care, and make recommendations for future research. We searched six multidisciplinary databases for academic literature published in English between January 2015 and May 2021. We also searched specific databases and websites for relevant grey literature. After screening, 59 academic articles and 18 grey literature sources were included for analysis. We identified five key findings: the public interest when regulating health professionals providing virtual care was only implicitly considered in most of the literature; when the public interest was discussed, the dimension of access was emphasized; criticism in the literature focused on social ideologies driving regulation that may inhibit more widespread use of virtual care; subnational licensure was viewed as a barrier; and the demand for virtual care during COVID-19 catalyzed licensure and scope of practice changes. Overall, virtual care introduces new areas of risk, potential harm, and inequity that health profession regulators need to address as technology continues to evolve. Regulators have an essential role in providing clear standards and guidelines around virtual care, including what is required for competent practice. There are indications that the public interest concept is evolving in relation to virtual care as regulators continue to balance public safety, equitable access to services, and economic competitiveness.

Regulating During Crisis: A Qualitative Comparative Case Study of Nursing Regulatory Responses to the COVID-19 Pandemic.

Background: The COVID-19 pandemic placed intense pressure on nursing regulatory bodies to ensure an adequate healthcare workforce while maintaining public safety. Purpose: Our objectives were to analyze regulatory bodies' responses during the pandemic, examine how nursing regulators conceptualize the public interest during a public health crisis, and explore the influence of a public health crisis on the balancing of regulatory principles. We aimed to develop a clearer understanding of regulating during a crisis by identifying themes within regulatory responses. Methods: We conducted a qualitative comparative case study examining the pandemic responses of eight nursing regulators in three Canadian provinces and three U.S. states. Data were collected from semi-structured interviews with 19 representatives of nursing regulatory bodies and 206 publicly available documents and analyzed thematically. Results: Five themes were constructed from the data: (1) risk-based responses to reduce regulatory burden; (2) agility and flexibility in regulatory pandemic responses; (3) working with stakeholders for a systems-based approach; (4) valuing consistency in regulatory approaches across jurisdictions; and (5) the pandemic as a catalyst for innovation. Specifically, we identified that the meaning of "public interest" in the context of high workforce demand was a key consideration for regulators. Conclusion: Our results demonstrate the intensity of effort involved in nursing regulatory responses and the significant contribution of nursing regulation to the healthcare system's pandemic response. Our results also indicate a shift in thinking around broader public interest issues, beyond the conduct and competence of individual nurses, to include pressing societal issues. Regulators are beginning to grapple with these longer-term issues and policy tensions.

The rocks and hard places of MAiD: a qualitative study of nursing practice in the context of legislated assisted death.

BACKGROUND: Medical Assistance in Dying (MAiD) was legalized in Canada in June, 2016. The Canadian government's decision to legislate assisted dying, an approach that requires a high degree of obligation, precision, and delegation, has resulted in unique challenges for health care and for nursing practice. The purpose of this study was to better understand the implications of a legislated approach to assisted death for nurses' experiences and nursing practice. METHODS: The study used a qualitative approach guided by Interpretive Description. Semi-structured interviews were conducted with 59 registered nurses and nurse practitioners. Interviews were audio-recorded, transcribed, and managed using qualitative analysis software. Analysis followed a procedure of data immersion, open coding, constant comparative analysis, and the construction of a thematic and interpretive account. RESULTS: Nurses in this study described great variability in how MAiD had been enacted in their work context and the practice supports available to guide their practice. The development of systems to support MAiD, or lack thereof, was largely driven by persons in influential leadership positions. Workplaces that supported a range of nurses' moral responses to MAiD were most effective in supporting nurses' well-being during this impactful change in practice. Participants cited the importance of teamwork in providing high quality MAiD-related care; although, many worked without the benefit of a team. Nursing work related to MAiD was highly complex, largely because of the need for patient-centered care in systems that were not always organized to support such care. In the absence of adequate practice supports, some nurses were choosing to limit their involvement in MAiD. CONCLUSIONS: Data obtained in this study suggested that some workplace contexts still lack the necessary supports for nurses to confidently meet the precision required of a legislated approach to MAiD. Without accessible palliative care, sufficient providers, a supportive team, practice supports, and a context that allowed nurses to have a range of responses to MAiD, nurses felt they were legally and morally at risk. Nurses seeking to provide the compassionate care consistent with such a momentous moment in patients' lives, without suitable supports, find themselves caught between the proverbial rock and hard place.

Medical assistance in dying: A political issue for nurses and nursing in Canada.

Death and dying are natural phenomena embedded within complex political, cultural and social systems. Nurses often practice at the forefront of this process and have a fundamental role in caring for both patients and those close to them during the process of dying and following death. While nursing has a rich tradition in advancing the palliative and end-of-life care movement, new modes of care for patients with serious and irremediable medical conditions arise when assisted death is legalized in a particular jurisdiction. In early 2015, the Supreme Court of Canada released its landmark decision Carter v. Canada (Attorney General) ('Carter'), which legalized physician-assisted suicide in particular clinical situations. The new law provided the broad national framework for Medical Assistance in Dying (MAiD) in Canada but, once the law was passed, provincial and territorial governments and health professional regulatory bodies each had to undertake a process of developing policies, procedures and processes to guide MAiD-related practice specific to their jurisdiction. In this paper, we begin to examine the political ramifications and professional tensions arising from MAiD for nurses and nursing, focusing specifically upon the impacts for registered nurses. We identify how variations in the provincial and territorial literature and regulatory guidelines across Canada have given rise to role confusion and uncertainty among some registered nurses and how this may potentially impact patient care. We then continue to highlight the need for greater political activism among nurses to foster greater clarity in nursing roles in MAiD and to advocate for improved supports for patients and those close to them.

But it's legal, isn't it? Law and ethics in nursing practice related to medical assistance in dying.

In June 2015, the Supreme Court of Canada struck down the Criminal Code's prohibition on assisted death. Just over a year later, the federal government crafted legislation to entrench medical assistance in dying (MAiD), the term used in Canada in place of physician-assisted death. Notably, Canada became the first country to allow nurse practitioners to act as assessors and providers, a result of a strong lobby by the Canadian Nurses Association. However, a legislated approach to assisted death has proven challenging in a number of areas. Although it facilitates a degree of accountability, precision and accessibility, it has also resulted in particular challenges negotiating the diverse perspectives of such a morally contentious act. One of these challenges is the tendency to conflate what is legal and what is moral in a modern liberal constitutionalism that places supreme value on autonomy and choice. Such a conflation tends to render invisible the legal and moral/ethical considerations necessary for nurses and nurse practitioners to remain ethical actors. In this paper, we introduce this conflation and then discuss the process of lawmaking in Canada, including the legalization of MAiD and the contributions of nursing to that legalization. We then engage in a hypothetical dialogue about the legal and moral/ethical implications of MAiD for nursing in Canada. We conclude with an appeal for morally sustainable workspaces that, when implementing MAiD, appropriately balance patient choices and nurses' moral well-being.

Medical Assistance in Dying: A Review of Canadian Nursing Regulatory Documents.

Canada's legalization of Medical Assistance in Dying (MAiD) in 2016 has had important implications for nursing regulators. Evidence indicates that registered nurses perform key roles in ensuring high-quality care for patients receiving MAiD. Further, Canada is the first country to recognize nurse practitioners as MAiD assessors and providers. The purpose of this article is to analyze the documents created by Canadian nursing regulatory bodies to support registered nurse and nurse practitioner practice in the political context of MAiD. A search of Canadian provincial and territorial websites retrieved 17 documents that provided regulatory guidance for registered nurses and nurse practitioners related to MAiD. Responsibilities of registered nurses varied across all documents reviewed but included assisting in assessment of patient competency, providing information about MAiD to patients and families, coordinating the MAiD process, preparing equipment and intravenous access for medication delivery, coordinating and informing health care personnel related to the MAiD procedure, documenting nursing care provided, supporting patients and significant others, and providing post death care. Responsibilities of nurse practitioners were identified in relation to existing legislation. Safety concerns cited in these documents related to ensuring that nurses understood their boundaries in relation to counseling versus informing, administering versus aiding, ensuring safeguards were met, obtaining informed consent, and documenting. Guidance related to conscientious objection figured prominently across documents. These findings have important implications for system level support for the nursing role in MAiD including ongoing education and support for nurses' moral decision making.

Community perspectives of end-of-life preparedness.

While death is a universal human experience, the process of planning for death can be difficult and may be avoided altogether. To understand community perspectives of end-of-life preparedness, we undertook a multimethod study exploring the experiences of 25 community members and 10 stakeholders engaged in end-of-life planning. In addition, card sorting activities and focused discussions with 97 older adults were undertaken to highlight perspectives and needs. Data were analyzed using descriptive statistics and qualitative description. Overall, the participants perceived many benefits to being end-of-life prepared, however, few community members had engaged in formal planning. Key barriers include concerns about the accessibility and accuracy of information, discomfort when engaging in end-of-life conversations, and perceptions about the cost associated with engaging in formal legal or financial preparations. Areas for further research include the need for studies that capture the cultural dimensions of end-of-life planning and explores the implementation and evaluation of community-based interventions to improve preparedness.

'It's complicated': Staff nurse perceptions of their influence on nursing students' learning. A qualitative descriptive study.

BACKGROUND: During both teacher-led clinical practica and precepted practica, students interact with, and learn from, staff nurses who work on the clinical units. It is understood that learning in clinical practice is enhanced by positive interactions between staff nurses and nursing students. While much is known about preceptors' experiences of working with nursing students, there is little evidence to date about staff nurses' perspectives of their interactions with students in teacher-led practica. PURPOSE: To understand teacher-led clinical practica from the perspective of staff nurses. METHOD: A qualitative descriptive approach answers the question: How do staff nurses perceive their contributions to nursing students' learning during teacher-led practica? Nine staff Registered Nurses (RNs) working within a regional acute care hospital in western Canada were interviewed using semi-structured interviews. Interview transcripts were analyzed using cross case analysis to discover themes and findings were checked by several experienced RNs. RESULTS: Analysis showed that nurses' interactions with nursing students are complicated. Nurses want to "train up" their future colleagues but feel a heavy burden of responsibility for students on the wards. This sense of burden for the staff nurses is influenced by several factors: the practice environment, the clinical instructor, the students themselves, and the nurses' understanding of their own contributions to student learning. CONCLUSIONS: Staff nurses remain willing to support student learning despite multiple factors that contribute to a sense of burden during teacher-led practica. Workplace environment, nursing program, and personal supports are needed to support their continuing engagement in student learning. Nurses need to know how important they are as role models, and the impact their casual interactions have on student nurses' socialization into the profession.

Teaching concept analysis to graduate nursing students.

AIM: To provide guidance to educators who use the Wilson (1963) concept analysis method, as modified by Walker and Avant (2011), in their graduate nursing curriculum BACKGROUND: While graduate nursing curricula often include a concept analysis assignment, there is a paucity of literature to assist educators in guiding students through this challenging process. DESIGN: This article details one way for educators to assist graduate nursing students in learning how to undertake each step of the Wilson (1963) concept analysis method, as modified by Walker and Avant (2011). DATA SOURCE: Wilson (1963) concept analysis method, as modified by Walker and Avant (2011). RESULTS: Using examples, this article walks the reader through the Walker and Avant (2011) concept analysis process and addresses those issues commonly encountered by educators during this process. CONCLUSION: This article presented one way of walking students through a Walker and Avant (2011) concept analysis. Having clear information about the steps involved in developing a concept analysis will make it easier for educators to incorporate it into their graduate nursing curriculum and to effectively guide students on their journey through this process.

Critical realism in nursing: an emerging approach.

Critical realism, a philosophical framework originally developed by Roy Bhaskar in the 1970s, represents a relatively new approach to research generally and to nursing research in particular. This article explores the ontological and epistemological tenets of critical realism and examines the application of critical realist principles to nursing research and practice through a review of the literature. It is evident that few published nursing research studies have, as of yet, utilized critical realism as their paradigm of choice. Both the strengths and limitations of the presentation and use of critical realism in these studies are discussed in this article. Given the varying degrees of success of the authors in explicating critical realism as a philosophical framework, the value of critical realism to the research study, and the ways in which usage of the critical realist framework influenced development of the study and interpretation of findings, it is evident that the quality of future publications espousing the use of critical realism must continue to be strengthened significantly.