Interventions to improve ethical decision-making skills in nursing students: A systematic review.

BACKGROUND: Interventions to improve ethical decision-making are available in nursing education. Evidence of its effectiveness is essential. OBJECTIVE: This review examined the effectiveness of interventions to improve nursing students' ethical decision-making skills. METHODS: A structured search was performed in Google Scholar, Web of Science, Science Direct, Pubmed, Scopus, Cochrane Library, Elsevier, CINAHL EBSCO, and ULAKBIM. The Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instruments (JBI-MAStARI) was used to assess the quality of studies. ETHICAL CONSIDERATIONS: Ethical approval was not required for this systematic review. FINDINGS: The final review was composed of six studies of published between January 2013 and 2023. Nine different teaching methods applied to students. Although the importance of ethical decision-making skills in solving ethical problems that nurses may encounter at any time is known, it is thought that there is a lack of data in the literature in the last 10 years. The last 10 years were chosen as this aims to provide a review based on the most current, relevant and quality information. The review indicated that all of the teaching methods improved ethical decision-making. CONCLUSION: Different teaching methods can be used in the nursing education curriculum to meet the learning needs of nursing students in ethical decision-making.

Critical care nurse leaders' moral distress: A qualitative descriptive study.

BACKGROUND: Unit-based critical care nurse leaders (UBCCNL) play a role in exemplifying ethical leadership, addressing moral distress, and mitigating contributing factors to moral distress on their units. Despite several studies examining the experience of moral distress by bedside nurses, knowledge is limited regarding the UBCCNL's experience. RESEARCH AIM: The aim of this study was to gain a deeper understanding of the lived experiences of Alabama UBCCNLs regarding how they experience, cope with, and address moral distress. RESEARCH DESIGN: A qualitative descriptive design and inductive thematic analysis guided the investigation. A screening and demographics questionnaire and a semi-structured interview protocol were the tools of data collection. PARTICIPANT AND RESEARCH CONTEXT: Data were collected from 10 UBCCNLs from seven hospitals across the state of Alabama from February to July 2023. ETHICAL CONSIDERATIONS: This study was approved by the Institutional Review Board at the University of Alabama in Huntsville. Informed consent was obtained from participants prior to data collection. FINDINGS: UBCCNLs experience moral distress frequently due to a variety of systemic and organizational barriers. Feelings of powerlessness tended to precipitate moral distress among UBCCNLs. Despite moral distress resulting in increased advocacy and empathy, UBCCNLs may experience a variety of negative responses resulting from moral distress. UBCCNLs may utilize internal and external mechanisms to cope with and address moral distress. CONCLUSIONS: The UBCCNL's experience of moral distress is not dissimilar from bedside staff; albeit, moral distress does occur as a result of the responsibilities of leadership and the associated systemic barriers that UBCCNLs are privier to. When organizations allocate resources for addressing moral distress, they should be convenient to leaders and staff. The UBCCNL perspective should be considered in the development of future moral distress measurement tools and interventions. Future research exploring the relationship between empathy and moral distress among nurse leaders is needed.

Canadian intensive care unit nurses' responses to moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions.

AIMS: To describe intensive care unit nurses' experiences of moral distress during the COVID-19 pandemic, and their recommendations for mitigative interventions. DESIGN: Interpretive description. METHODS: Data were collected with a purposeful sample of 40 Canadian intensive care unit nurses between May and September 2021. Nurses completed a demographic questionnaire, the Measure of Moral Distress-Healthcare Professionals survey and in-depth interviews. Quantitative data were analysed using descriptive statistics. Qualitative data were categorized and synthesized using reflexive thematic analysis and rapid qualitative analysis. RESULTS: Half of the nurses in this sample reported moderate levels of moral distress. In response to moral distress, nurses experienced immediate and long-term effects across multiple health domains. To cope, nurses discussed varied reactions, including action, avoidance and acquiescence. Nurses provided recommendations for interventions across multiple organizations to mitigate moral distress and negative health outcomes. CONCLUSION: Nurses reported that moral distress drove negative health outcomes and attrition in response to moral events in practice. To change these conditions of moral distress, nurses require organizational investments in interventions and cultures that prioritize the inclusion of nursing perspectives and voices. IMPLICATIONS FOR THE PROFESSION: Nurses engage in a variety of responses to cope with moral distress. They possess valuable insights into the practice issues central to moral distress that have significant implications for all members of the healthcare teams, patients and systems. It is essential that nurses' voices be included in the development of future interventions central to the responses to moral distress. REPORTING METHOD: This study adheres to COREQ guidelines. IMPACT: What Problem did the Study Address? Given the known structural, systemic and environmental factors that contribute to intensive care unit nurses' experiences of moral distress, and ultimately burnout and attrition, it was important to learn about their experiences of moral distress and their recommendations for organizational mitigative interventions. Documentation of these experiences and recommendations took on a greater urgency during the context of a global health emergency, the COVID-19 pandemic, where such contextual influences on moral distress were less understood. What Were the Main Findings? Over half of the nurses reported a moderate level of moral distress. Nurses who were considering leaving nursing practice reported higher moral distress scores than those who were not considering leaving. In response to moral distress, nurses experienced a variety of outcomes across several health domains. To cope with moral distress, nurses engaged in patterns of action, avoidance and acquiescence. To change the conditions of moral distress, nurses desire organizational interventions, practices and culture changes situated in the amplification of their voices. Where and on Whom Will the Research Have an Impact on? These findings will be of interest to: (1) researchers developing and evaluating interventions that address the complex phenomenon of moral distress, (2) leaders and administrators in hospitals, and relevant healthcare and nursing organizations, and (3) nurses interested in leveraging evidence-informed recommendations to advocate for interventions to address moral distress. What Does this Paper Contribute to the Wider Global Community? This paper advances the body of scientific work on nurses' experiences of moral distress, capturing this phenomenon within the unique context of a global health emergency. Nurses' levels of moral distress using Measure of Moral Distress-Healthcare Professional survey were reported, serving as a comparator for future studies seeking to measure and evaluate intensive care unit nurses' levels of moral distress. Nurses' recommendations for mitigative interventions for moral distress have been reported, which can help inform future interventional studies. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Ethical considerations for artificial intelligence use in nursing informatics.

Artificial intelligence revolutionizes nursing informatics and healthcare by enhancing patient outcomes and healthcare access while streamlining nursing workflow. These advancements, while promising, have sparked debates on traditional nursing ethics like patient data handling and implicit bias. The key to unlocking the next frontier in holistic nursing care lies in nurses navigating the delicate balance between artificial intelligence and the core values of empathy and compassion. Mindful utilization of artificial intelligence coupled with an unwavering ethical commitment by nurses may transform the very essence of nursing.

The relationship between nurses' moral courage and whistleblowing approaches.

BACKGROUND: Whistleblowing is an action that particularly requires moral courage. Understanding the relationship between nurses' levels of moral courage and their whistleblowing approaches is important for reducing adverse situations in healthcare services. OBJECTIVES: This study aims to understand and analyze the relationship between nurses' levels of moral courage and their whistleblowing approaches. RESEARCH DESIGN: This is a descriptive and correlational study. METHODS: The study sample consists of 582 nurses actively working in a province in northwest Türkiye. Research data were collected using an Information Form, the Nurses' Moral Courage Scale, and the Whistleblowing Scale. ETHICAL CONSIDERATIONS: Ethical approval from the ethics committee, institutional permission, and informed consent from the participants were obtained for data collection. FINDINGS: Nurses were found to perceive their moral courage as high, and their whistleblowing levels were at a moderate level. There was a significant and moderate relationship between participants' levels of moral courage and whistleblowing levels (p < .05). CONCLUSIONS: The findings emphasize the importance of promoting moral courage and creating an appropriate environment for exposing ethical violations. This study can contribute to the development of strategies to enhance nurses' moral courage and foster a more ethical working environment in healthcare services.

Enhancing the moral courage of nurses: A modified Delphi study.

BACKGROUND: The urgency of ensuring adequate moral courage in clinical nursing practice is evident. However, currently, there are few formal intervention plans targeted at enhancing the moral courage of nurses. AIM: To develop a training program for improving the moral courage of nurses using the modified Delphi method. RESEARCH DESIGN: A modified Delphi study. PARTICIPANTS AND RESEARCH CONTEXT: From November to December 2022, a literature review and expert group discussion were conducted to develop a preliminary training plan framework. From January to March 2023, a two-round Delphi survey was performed, and a consensus was reached regarding the plan through online questionnaires. Descriptive statistics were used to analyze the data. ETHICAL CONSIDERATIONS: This study was approved by the institutional ethics committee (No. 138, 30 August 2021). All participants provided written informed consent. RESULTS: Consensus was reached on eight themes and 33 items to strengthen the moral courage training program for nurses. CONCLUSIONS: Guided by a unified goal of moral education, a multi-level and acceptable intervention plan was designed to enhance the moral courage of nurses.

Nurses' ethical responsibilities: Whistleblowing and advocacy in patient safety.

BACKGROUND: In the dynamic landscape of healthcare, nurses play a crucial role as ethical stewards, responsible for whistleblowing, nurse advocacy, and patient safety. Their duties involve ensuring patient well-being through ethical practices and advocacy initiatives. AIM: This study investigates the ethical responsibilities of nurses regarding whistleblowing and advocacy in reporting concerns about patient safety. RESEARCH DESIGN: A cross-sectional study utilized cluster and simple random sampling to gather a representative sample of actively practicing registered nurses. Data collection involved a demographic form, Nurse Whistleblowing Intentions Scale, Nursing Advocacy Scale, and Clinical Decision-Making Scale. PARTICIPANTS AND RESEARCH CONTEXT: The study utilizing a robust sample size determination formula for reliable findings included 96 diverse nurses, predominantly females. Engaged actively in direct patient care across various outpatients clinics. The recruitment process specifically sought individuals with expertise in safety protocols and reporting, contributing to a nuanced understanding of the study's focus. ETHICAL CONSIDERATIONS: Ethical approval was obtained from the ethics committee of the university and the hospitals involved. Written consent was obtained from the participants. A thorough ethical review was conducted to guarantee participant protection and adherence to ethical principles. RESULTS: Surveyed nurses demonstrated positive whistleblowing (Overall Mean Score: 3.58), high advocacy (Overall Mean Score: 12.2), and nuanced ethical decision-making for patient safety (Overall Mean Score: 15.78). Demographic factors, such as nationality and ethical training, significantly impacted whistleblowing intentions, while age, gender, and ethical training correlated with nursing advocacy behavior. Associations with experience and qualification emerged in ethical decision-making. CONCLUSION: The gained insights foster targeted interventions, improving ethical practices, advocacy, and informed decision-making in nursing. This study explores the intricate link between demographics and ethical considerations among surveyed nurses, acting as a catalyst for ongoing initiatives to strengthen the ethical foundation in healthcare sector.

From informed to empowered consent.

Informed consent is ethically incomplete and should be redefined as empowered consent. This essay challenges theoretical assumptions of the value of informed consent in light of substantial evidence of its failure in clinical practice and questions the continued emphasis on autonomy as the primary ethical justification for the practice of consent in health care. Human dignity-rather than autonomy-is advanced from a nursing ethics perspective as a preferred justification for consent practices in health care. The adequacy of an ethic of obligation (namely, principlism) as the dominant theoretical lens for recognising and responding to persistent problems in consent practices is also reconsidered. A feminist empowerment framework is adopted as an alternative ethical theory to principlism and is advanced as a more practical and complete lens for examining the concept and context of consent in health care. To accomplish this, the three leading conceptions of informed consent are overviewed, followed by a feminist critique to reveal practical problems with each of them. The need for a language change from informed to empowered consent is strongly considered. Implications for consent activities in clinical practice are reviewed with focused discussion on the need for greater role clarity for all involved in consent-beyond and inclusive of the patient-physician dyad, as the practice and improvement of consent is necessarily a transdisciplinary endeavour. Specific concrete and practical recommendations for leveraging nursing expertise in this space are presented. Perhaps what is most needed in the discourse and practice of consent in health care is nursing.

Brave spaces in nursing ethics education: Courage through pedagogy.

BACKGROUND: Nursing students must graduate prepared to bravely enact the art and science of nursing in environments infiltrated with ethical challenges. Given the necessity and moral obligation of nurses to engage in discourse within nursing ethics, nursing students must be provided a moral supportive learning space for these opportunities. Situating conversations and pedagogy within a brave space may offer a framework to engage in civil discourse while fostering moral courage for learners. RESEARCH OBJECTIVE: The aim of this research is to explore the influence of a structured self-assessment tool called the ESA "Engagement Self-Assessment" on the alignment and creation of a brave space in a nursing ethics course. RESEARCH DESIGN: This study used an exploratory, cross-sectional survey design. PARTICIPANTS AND STUDY SETTING: Data from 39 undergraduate nursing students enrolled in a nursing healthcare ethics & law course using the ESA were recruited. ETHICAL CONSIDERATIONS: Participation was voluntary and informed without coercion. Written consent was obtained prior to participation. Research ethics approval was obtained by the Institutional Research Ethics Board of the recruited participants (Ethics # 2022-23-03). FINDINGS: The ESA provided structured self-reflection on the impact of shared vulnerability within a brave space. However, commitment to a brave space was not strongly influenced by the ESA, but rather by a mutual "commitment to others." CONCLUSION: A teaching tool such as an ESA can be used to facilitate instructor expectations of civil discourse and discussion of difficult topics. Rules of engagement such as those found in brave spaces can help transform fear of vulnerability into authentic growth for learners. A morally supportive learning space can support critical opportunities for ethical development. This study provides insight into how self-assessment and the use of a brave space in nursing ethics education can facilitate a morally supportive learning space.

Promoting moral imagination in nursing education: Imagining and performing.

Moral imagination is a central component of moral agency and person-centred care. Becoming moral agents who can sustain attention on patients and their families through their illness and suffering involves imagining the other, what moral possibilities are available, what choices to make, and how one wants to be. This relationship between moral agency, moral imagination, and personhood can be effaced by a focus on task-driven technical rationality within the multifaceted challenges of contemporary healthcare. Similarly, facilitating students' moral agency can also be obscured by the task-driven technical rationality of teaching. The development of moral agency requires deliberate attention across the trajectory of nursing education. To prepare nursing students for one practice challenge, workplace violence, we developed a multimodal education intervention which included a simulated learning experience (SLE). To enhance the realism and consistency of the educational experience, 11 nursing students were trained as simulated participants (SP). As part of a larger study to examine knowledge acquisition and practice confidence of learners who completed the SLE, we explored the experience of being the SP through interviews and a focus group with the SP students. The SP described how their multiple performances contributed to imagining the situation 'on both sides' prompting empathy, a reconsideration of their moral agency, and the potential to prevent violence in the workplace beyond technical rational techniques, such as verbal de-escalation scripts. The empirical findings from the SP prompted a philosophical exploration into moral imagination. We summarise the multimodal educational intervention and relevant findings, and then, using Johnson's conception of moral imagination and relevant nursing literature, we discuss the significance of the SP embodied experiences and their professional formation. We suggest that SLEs offer a unique avenue to create pedagogical spaces which promote moral imagination, thereby teaching for moral agency and person-centred care.

Am I my students' nurse? Reflections on the nursing ethics of nursing education.

Despite having worked in higher education for over twenty years, I am still, first and foremost, a practicing nurse. My employer requires me to be a nurse and my regulator regards what I do as nursing. My practice is regulated by the Code and informed by nursing ethics. If I am nurse, practicing nursing, does that mean that my students are my patients? This paper considers how the relationship that I have with my students can be informed by the ethics of the nurse/patient relationship. After some initial theoretical preparation concerning argument from analogy, the paper identifies some areas for comparison between the two relationships. Areas of similarity and difference identify two areas of concern: Nurse education and educators regularly engage in coercion and surveillance in an attempt to increase student success, both of which would be considered outside nursing ethics. It is concluded that these coercive practices are not conducive to an environment where character is cultivated. Despite current financial and workforce pressures, nurse lecturers and more especially their managers would do well to return to the professional ethics of nursing to question and guide their practice.

A quantitative survey measure of moral evaluations of patient substance misuse among health professionals in California, urban France, and urban China.

BACKGROUND: The merits and drawbacks of moral relevance models of addiction have predominantly been discussed theoretically, without empirical evidence of these potential effects. This study develops and evaluates a novel survey measure for assessing moral evaluations of patient substance misuse (ME-PSM). METHODS: This measure was tested on 524 health professionals (i.e., physicians, nurses, and other health professionals) in California (n = 173), urban France (n = 102), and urban China (n = 249). Demographic factors associated with ME-PSM were investigated using analyses of variance (ANOVAs) and t-tests, with results suggesting that ME-PSM is higher among younger health professionals, nurses (when compared with physicians and other health professionals), and Chinese health professionals (when compared with French and American health professionals). RESULTS: Results provide preliminary support for the psychometric quality of the survey measure introduced in this study, including the existence of a single latent structure and partial invariance of collected data across countries. CONCLUSION: The survey measure for ME-PSM which was developed and tested in the current study appears to hold potential utility for use as a measure of moral views of patient substance misuse. With development, this measure may be used to examine moral evaluations, both as factors of stigma and of other clinical factors associated with the treatment of patients with substance use disorders.

Challenges regarding informed consent in recruitment to clinical research: a qualitative study of clinical research nurses' experiences.

BACKGROUND: Clinical research nurses (CRNs) have first-hand experience with ethical challenges and play a crucial role in upholding ethical conduct and adherence to the principles of informed consent in clinical research. This study explores the ethical challenges encountered by CRNs in the process of obtaining informed consent for clinical research. METHODS: A qualitative exploratory design. Semistructured interviews (n = 14) were conducted with diverse CRNs in Sweden. These CRNs covered a wide range of research fields, including pharmaceutical and academic studies, interventions, and observational research, spanning different trial phases, patient categories, and medical conditions. The interviews were analysed using inductive qualitative content analysis. RESULTS: The analysis identified three main categories: (i) threats to voluntariness, (ii) measures to safeguard voluntariness, and (iii) questionable exclusion of certain groups. CRNs face challenges due to time constraints, rushed decisions, information overload, and excessive reliance on physicians' recommendations. Overestimating therapeutic benefits in stages of advanced illness emerged as a risk to voluntariness. CRNs outlined proactive solutions, such as allowing ample decision-making time and offering support, especially for terminally ill patients. Concerns were also voiced about excluding certain demographics, such as those with language barriers or cognitive impairments. CONCLUSIONS: In conclusion, upholding ethical research standards requires recognising various factors affecting patient voluntariness. Researchers and CRNs should prioritise refining the informed consent process, overcoming participation challenges, and aligning scientific rigour with personalised care. Additionally, a concerted effort is vital to meet the diverse needs of patient populations, including equitable inclusion of individuals with language barriers or cognitive limitations in clinical studies. These findings have significant implications for enhancing the ethics of clinical research and advancing person-centred care.

[Live-ins: A mapping of relevant actors and moral norms at the public health level]. / Live-Ins: Eine Kartierung relevanter Akteur_innen und moralischer Normen auf der Public-Health-Ebene.

Live-ins: A mapping of relevant actors and moral norms at the public health level Abstract: Background: Live-ins are embedded in a network of multiple actors that shape their current working and living situation. The causes and effects of live-in arrangements go far beyond the actual care relationship and include structures and stakeholders that are interconnected at the Public Health level. Besides a legal responsibility, these actors also have a moral responsibility, which the article focuses on. Aim: The article provides an overview of relevant actors and moral norms in the context of live-ins at the public health level. Methods: The method followed the "Context and Actor Analysis". Actors at the public health level that are relevant for the live-ins' situation were identified, and the responsibilities and tasks presented in their websites as well as their respective target groups were collected. The ethical dimension was extracted from these self-descriptions. Results: The 23 actors address the live-ins directly or indirectly in their various social roles. The self-given tasks and the moral norms deduced from them, for which the actors are particularly responsible, illustrate the importance of justice and respect. Conclusions: The work provides the basis for an urgently needed empirical-ethical analysis on the current state of responsibility-taking. Not only the variety of the live-ins' roles, but also the multitude of actors involved and shared norms illustrate the necessity of close cooperation to be able to fulfil their responsibility.

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.

E-walks bring ethics to the bedside: A nurse ethicist's reflections.

The unique role of the nurse ethicist in the clinical setting is one meant to enhance the ethical capacity of nurses, and front-line healthcare providers. As a nurse ethicist, it is also my goal to enhance the ethical climate of each individual work area, patient care unit, and the broader institution by encouraging ethical conversations, navigating ethical dilemmas, and seeking creative solutions to minimize moral distress and burnout. To provide preventive ethics support and education, I began regularly visiting patient care areas for ethics rounds, which I affectionately named "E-walks" (for Ethics Walks). I will discuss and reflect upon the lessons that have emerged as three key components of "E-Walks": Recognition, Solidarity and Dialogue. These themes will speak to the unique presence and availability of a nurse ethicist as a valuable resource to front-line healthcare providers who face ethical dilemmas and morally concerning cases. I will go on to argue and demonstrate that my role as the nurse ethicist lies at the intersection of bioethics and the theoretical framework of the "ethic of care," which is focused on building, creating, and sustaining caring interprofessional relationships through the work of ethics, nursing, and education.

Operationalizing the role of the nurse ethicist: More than a job.

The idea of a role in nursing that includes expertise in ethics has been around for more than 30 years. Whether or not one subscribes to the idea that nursing ethics is separate and distinct from bioethics, nursing practice has much to contribute to the ethical practice of healthcare, and with the strong grounding in ethics and aspiration for social justice considerations in nursing, there is no wonder that the specific role of the nurse ethicist has emerged. Nurse ethicists, expert in nursing practice and the application of ethical theories and concepts, are well positioned to guide nurses through complex ethical challenges. However, there is limited discussion within the field regarding the specific job responsibilities that the nurse ethicist ought to have. The recent appearance of job postings with the title "nurse ethicist" suggest that some healthcare institutions have identified the value of a nurse in the practice of ethics and are actively recruiting. Discomfort about the possibility of others defining the role of the nurse ethicist inspired this paper (and special issue). If the nurse ethicist is to be seen as an integral part of addressing ethical dilemmas and ethical conflicts that arise in healthcare, then nurse ethicists ought to be at the forefront of defining this role. In this paper, we draw upon our own experiences as nurse ethicists in large academic healthcare systems to describe the essential elements that ought to be addressed in a job description for a nurse ethicist practicing in a clinical setting linked to academic programs. Drawing upon our experience and the literature, we describe how we perceive the nurse ethicist adds value to healthcare organizations and teams of professional ethicists.

Nurse ethicists: Innovative resource or ideological aspiration?

In recent years, there have been growing calls for nurses to have a formal advanced practice role as nurse ethicists in hospital contexts. Initially proposed in the cultural context of the USA where nurse ethicists have long been recognised, the idea is being advocated in other judications outside of the USA such as the UK, Australia and elsewhere. Such calls are not without controversy, however. Underpinning this controversy are ongoing debates about the theoretical, methodological and political dimensions of clinical ethics support services generally, and more recently where nurses might 'fit' within such a service. In considering whether nurse ethicists ought to have a place in clinical ethics support services, a number of questions arise such as: Is such a role warranted? If so, what credentials should nurses assuming the title of 'nurse ethicist' be required to have? What standards of practice ought nurse ethicists be required to uphold? What is the ultimate role and function of nurse ethicists in hospital contexts? And in what contexts might a nurse ethicist be most useful? In this essay, brief attention will be given to addressing these questions. It will be concluded that, as a minimum, nurses wishing to assume an advanced nursing practice role as a nurse ethicist must have substantive grounding in the foundational knowledge of the disciplines of both moral philosophy and nursing ethics. They must also not lose sight of the ultimate goal of nursing ethics, notably, to promote and advance ethical nursing practice and the provision of 'good' nursing care.

Undocumented migrants' access to healthcare in Sweden, and the impact of Act 2013:407.

BACKGROUND: Research shows that undocumented migrants have difficulties in accessing healthcare. Act 2013:407 came into force in 2013 and entitled undocumented migrants to healthcare that cannot be deferred. To date, studies about undocumented migrants' access to care in Sweden and the impact of Act 2013:407 are sparse. Hence, the aim of this study was to describe professionals' experiences of access to healthcare for undocumented migrants in Sweden and the impact of Act 2013:407. METHODS: A qualitative design with semi-structured interviews was employed. Nine interviews were carried out in 2015 with nurses at two NGO healthcare centres for undocumented migrants - and an additional seven interviews in 2022 with staff at an NGO healthcare centre for undocumented migrants and personnel at a regional health and medical care administration. Interpretive description was used for the analyses. ETHICAL CONSIDERATIONS: Permission to carry out the study was obtained from managers at the participating NGOs and the regional health and medical care administration. Participants received verbal and written information about the study, and informed consent was obtained from all participants. FINDINGS: Six categories emerged from the analysis: Changes since the Act was introduced, General problems with healthcare access, Care for undocumented migrants - politics and social economy, Lack of knowledge, 'Healthcare that cannot be deferred' and Being an undocumented migrant. CONCLUSION: Undocumented migrants' social needs are as great as their needs for healthcare. Healthcare staff are burdened with healthcare cost considerations which affect their judgement of care provision and prioritization. Healthcare staff attitudes towards undocumented migrants affect their access to healthcare. Undocumented migrants in need of healthcare are especially vulnerable due to their legal status, being ill and the fear of being reported and deported. To assure undocumented migrants' access to healthcare and maintain healthcare ethics, the only possible solution is to provide healthcare based on needs.

Empathy and ethical sensitivity among intensive and critical care nurses: A path analysis.

BACKGROUND: Intensive and critical care nurses need to demonstrate ethical sensitivity especially in recognizing and dealing with ethical dilemmas particularly as they often care for patients living with life-threatening conditions. Theories suggest that there is a convergence between nurses' empathy and ethical sensitivity. Evidence in the literature indicates that nurses' emotional, demographic, and work characteristics are associated with their level of empathy and ethical sensitivity. AIM: To investigate the relationship between nurses' empathy and ethical sensitivity, considering their emotional states (depression, anxiety, and stress), demographic and work characteristics, and test an empirical model describing potential predictors of empathy (as a mediator) and ethical sensitivity using path analysis. RESEARCH DESIGN: Using a cross-sectional design, the philosophical theory of care ethics and empathy was extended and adopted as a conceptual framework for this study and tested by path analysis. PARTICIPANTS AND RESEARCH CONTEXT: Data were collected from 347 intensive care nurses recruited by ten educational-medical hospitals in Iran using a questionnaire between February and March 2021. ETHICAL CONSIDERATIONS: The study was reviewed by the Ethical Advisory Board in Iran and conducted according to the Declaration of Helsinki. FINDINGS: Study participants demonstrated a mild level of stress, anxiety, and depression, alongside a relatively high level of empathy and ethical sensitivity. Nurses with good socioeconomic status had higher empathetic behavior with patients than those with weak status. Nurses aged over 40 who had received ethics training and had higher work experience were associated with higher ethical sensitivity compared to nurses under 20 years of age. Empathy directly affected ethical sensitivity; however, anxiety had an indirect effect on ethical sensitivity through empathy. Among demographic factors, age had a positive direct effect on ethical sensitivity. CONCLUSIONS: Less anxiety and a high level of empathy contribute to higher levels of ethical sensitivity among intensive and critical care nurses.