Nudging in nursing.

Nudging is a concept in behavioural science, political theory and economics that proposes indirect suggestions to try to achieve non-forced compliance and to influence the decision making and behaviour of groups and individuals. Researchers in medical ethics are currently discussing whether nudging is ethically permissible in healthcare. In this article, we examine current knowledge about how different decisions (rational and pre-rational decisions, major and minor decisions) are made and how this decision-making process pertains to patients. We view this knowledge in light of the nursing project and the ongoing debate regarding the ethical legitimacy of nudging in healthcare. We argue that it is insufficient to discuss nudging in nursing and healthcare in light of free will and patient autonomy alone. Sometimes, nurses must take charge and exhibit leadership in the nurse-patient relationship. From the perspective of nursing as leadership, nudging becomes a useful tool for directing and guiding patients towards the shared goals of health, recovery and independence and away from suffering. The use of nudging in nursing to influence patients' decisions and actions must be in alignment with the nursing project and in accordance with patients' own values and goals.

Ethical Challenges Unique to the Primary Care Behavioral Health (PCBH) Model.

The interprofessional nature of the Primary Care Behavioral Health (PCBH) model invites potential conflicts between different ethical guidelines and principles developed by separate professional disciplines. When the foundational model of care and training on which ethical principles were developed shifts, the assumptions underlying the guidance also shifts, revealing gaps and mismatches. This article reviews the extant literature in this realm, and proposes a more unifying set of ethical guidance for interprofessional, integrated primary care practice. We discuss common ethical dilemmas unique to the PCBH model through case examples, and then apply the newly proposed ethical guideline model to these cases to illustrate how the newly proposed model can be efficient and effective navigating these dilemmas.

A good training based on insufficiency: Work in health care as an ethics.

The article discusses psychology training in health care at the Federal University of São Paulo. It places curriculum guidelines in a changing movement of training for health professions, proposing Work in Health Care as one of its common axes. In the Baixada Santista campus, the course is based on learning by experience, public health services and multidisciplinary team work. Three vectors derived from the experience in this project and its assessment are discussed: a common clinic, work in health care as an ethics and the idea of good training by insufficiency.

Neuroética: la dotación ética del cerebro humano / Neuroethics: ethical endowments of human brain

Los procesos neurobiológicos que subyacen al juicio ético es el foco de atención de la Neuroética. El conocimiento, desde las neurociencias, de qué áreas cerebrales se activan y cuales se silencian mientras las personas deciden cómo actuar ante un dilema moral, ha permitido conocer los correlatos cerebrales que subyacen a los actos humanos y ofrecer una explicación de cómo está impresa en la dinámica del cerebro la dotación ética de cada hombre y común a todos los hombres. De interés central es el papel causal que desempeñan las emociones en el juicio ético y en paralelo las áreas cerebrales relacionadas con las emociones. La finalidad de las inclinaciones naturales del hombre están fuertemente atadas, por hundir sus raíces en los sistemas instintivos de la supervivencia animal, sensible a las emociones básicas; y al mismo tiempo, e inseparablemente, la vida de cada hombre está liberada del automatismo de tales leyes, es decir, regido por la ley de la libertad. El juicio ético es propiedad innata de la mente (AU)

The neurobiological processes underlying moral judgement have been the focus of Neuroethics. Neurosciences demonstrate which cerebral areas are active and inactive whilst people decide how to act when facing a moral dilemma; in this way we know the correlation between determined cerebral areas and our human acts. We can explain how the 'ethical endowments' of each person, common to all human beings, is 'embedded' in the dynamic of cerebral flows. Of central interest is whether emotions play a causal role in moral judgement, and, in parallel, how emotion-related areas of the brain contribute to moral judgement. The outcome of man’s natural inclinations is on one hand linked to instinctive systems of animal survival and to basic emotions, and on the other, to the life of each individual human uninhibited by automatism of the biological laws, because he is governed by the laws of freedom. The capacity to formulate an ethical judgement is an innate asset of the human mind (AU)

Disaster behavioral health: legal and ethical considerations in a rapidly changing field.

Disaster behavioral health is increasingly regarded as a central part of disaster preparedness, response and recovery. Legal and ethical issues have received relatively little attention and have sparked divergent opinions. Optimally, understanding and applying legal and ethical considerations requires an understanding of the evolution of the disaster behavioral health field and the context of disaster response and recovery. In addition, there are many legal and ethical questions identified for consideration, and many ways to approach reaching understanding and consensus. Traditionally, discussions of disaster behavioral health, including legal and ethical issues, have not included understanding decision making processes that occur in extreme circumstances. Models which interpret disaster response operations as complex adaptive systems are presented for consideration as useful tools for preparing mental health workers for effectively delivering services in acute disaster response environments.

Towards a new theory of practice for community health psychology.

The article sets out the value of theorizing collective action from a social science perspective that engages with the messy actuality of practice. It argues that community health psychology relies on an abstract version of Paulo Freire's earlier writing, the Pedagogy of the Oppressed, which provides scholar-activists with a 'map' approach to collective action. The article revisits Freire's later work, the Pedagogy of Hope, and argues for the importance of developing a 'journey' approach to collective action. Theories of practice are discussed for their value in theorizing such journeys, and in bringing maps (intentions) and journeys (actuality) closer together.

Ethical issues facing providers in collaborative primary care settings: do current guidelines suffice to guide the future of team based primary care?

This special issue discusses the ethical issues providers face in collaborative primary care settings. It is organized in three sections: (a) Common Themes, (b) Context-Specific Quandaries, and (c) Research and Training. It provides case examples to illustrate ethical dilemmas, describe professional ethical standards pertinent to the case, identifies gaps in available guidance and how guidelines might be elucidated in state statues (without going into detail about specific states), offers feasible recommendations to BHCs for deciding an ethical course when extant guidance was lacking, and then demonstrates and applies the recommendations to achieve an ethical resolution to the case example.

The ethics of complex relationships in primary care behavioral health.

Primary care settings are particularly prone to complex relationships that can be ethically challenging. This is due in part to three of the distinctive attributes of primary care: a whole family orientation; team-based care; and a longitudinal care delivery model. In addition, the high patient volume of primary care means that the likelihood of encountering ethically challenging relationships is probably greater than in a specialty setting. This article argues that one ethical standard of the American Psychological Association (APA, 2010, Ethical principles of psychologists and code of conduct, www.apa.org/ethics/code) (10.02, Therapy Involving Couples or Families) should be revised to better accommodate the work of psychologists in primary care. The corresponding Principles of Medical Ethics from the American Medical Association (AMA, 2012, Code of medical ethics: Current opinions with annotations, 2012-2013, Washington, DC: Author), most notably the principle regarding a physician's duty to "respect the rights of patients, colleagues, and other health professionals as well as safeguard privacy" are also noted. In addition, the article details how the three attributes of primary care often result in complex relationships, and provides suggestions for handling such relationships ethically.

Navigating the legal and ethical foundations of informed consent and confidentiality in integrated primary care.

This article describes findings from ongoing research and analysis of current literature in addition to discussions with leaders in the field, communications with lawyers and administrators of advocacy and government agencies pertaining to integrated primary care (IPC). Standards of care are established based on a myriad of factors, including professional codes of ethics, case law, state and federal laws, professional standards, existing best practices, current professional guidelines, administrative rules and regulations, and licensing board regulations. Regulations may differ for behavioral health and medical providers, posing challenges in IPC settings. This article provides a review of these regulations, particularly 42CFR Part 2, a federal law governing confidentiality for substance abuse programs, Health Insurance Portability and Accountability Act (HIPAA), and state laws relevant to patient care in IPC settings. On the basis of findings from the study, the authors make recommendations related to patient care practices concerning informed consent and release of information procedures, treatment and warm hand-off protocols, documentation and electronic record keeping, agreements with other providers, and billing.

Patient and provider relationships: consent, confidentiality, and managing mistakes in integrated primary care settings.

Health care in the United States is advancing toward increasingly integrated primary care systems. With this evolution comes a responsibility for providers to carefully consider a variety of issues related to ethical conduct. While working within the same teams on behalf of the same patients and families, professionals representing different disciplines are guided by different sets of baseline ethics guidelines and codes-and the overlap and differences between these principles can easily translate into ethical breaches. Using a clinical vignette as the basis for our discussion, we address issues of informed consent, confidentiality, and grievance procedures specifically. We review extant literature and formal ethics codes upheld by nine leading professional organizations across these foci, offer recommendations about how to manage this clinical scenario, and highlight what is needed to advance our understanding of integration ethics.

Primary care provider reflections on common themes from special issue on ethical quandaries when delivering integrated primary care.

Comments on the articles by Hudgins, Rose, Fifield, & Arnault, (see record 2013-11498-002), Reiter & Runyan, (see record 2013-11498-003), Hodgson, Mendenhall, & Lamson (see record 2013-11498-004), and Kanzler, Goodie, Hunter, Glotfelter, & Bodart (see record 2013-11498-005), regarding the topic of common themes for the special issue on ethical quandaries when delivering integrated primary care. The current author provides brief reflections on each article.

Ethical quandaries in caring for primary-care patients with chronic pain.

In the past decade, more and more behavioral health providers have begun consultation practices in primary-care settings. Their availability makes multidisciplinary care a reality and the possibility of improved outcomes for patients with chronic pain more feasible. However, behavioral health providers encounter new ethical quandaries in providing services to patients with chronic pain and to the primary-care providers who plan their treatment. This article presents two cases to illustrate the questions that arise in delivery of primary-care behavioral health services to patients with chronic pain. Relevant professional ethical guidelines for psychologists, social workers, and physicians are examined and recommendations for addressing the gaps in extant guides are offered.

Primary care behavioral health: ethical issues in military settings.

The rapid expansion of integrated behavioral health care in primary care medical settings introduces a number of ethical challenges faced by teams of health professionals from different disciplines. As military health care settings have increasingly implemented primary care behavioral health models of service delivery, distinct ethical dilemmas have emerged. This article examines two of these ethical issues, competence and multiple relationships, through presentation of clinical scenarios in military integrated primary care settings. Relevant professional ethical guidelines for psychologists, social workers, and physicians are examined. Recommendations for the ethical practice of primary care behavioral health, as well as suggestions for future development of professional ethical guidelines, are discussed.

Ethical matters in rural integrated primary care settings.

Integrated primary care is particularly valuable to rural communities. Behavioral health care is often in short supply, and small or close-knit communities can intensify the stigma of seeking specialty mental health in rural settings. These and other barriers result in reduced access to needed behavioral health care. Nonetheless, rural practice of integrated primary care presents unique challenges to practitioners of multiple disciplines, including issues of competence, confidentiality, and dual relationships. This article provides an illustrative vignette to describe ethical issues in the rural practice of integrated primary care. It will review discipline-specific guidance in approaching these challenges and will offer recommendations for addressing disparities in the approaches of various disciplines engaged in the practice of integrated primary care.

Integrating care when the end is near: ethical dilemmas in end-of-life care.

An integrated and collaborative team provides the best clinical care of patients and families during end-of-life moments. Behavioral Health Clinicians (BHCs) bring a skill set for facilitating team interactions, attending to group process, as well as making space for the patient or family voice in the care, often with more time available for these roles. Through a case scenario, this article explores the relevant existing codes of ethics and professional conduct for professionals practicing in integrated care settings as they pertain to end-of-life transitions and care. Most notably, potential ethical issues pertaining to patient autonomy, scope of practice, confidentiality, multiple relationships, and record keeping all come to play during end-of-life care when practicing in an integrated primary care setting. Gaps in the existing codes are discussed and recommendations for providing ethically informed patient- and family-centered end-of-life care are suggested.

Primary care provider reflections on context-specific quandaries from special issue on ethical quandaries when delivering integrated primary care.

Comments on the articles by Robinson & Rickard, (see record 2013-11498-007), Dobmeyer, (see record 2013-11498-008), Mullin & Stenger (see record 2013-11498-009), and Rosenberg & Speice (see record 2013-11498-010) regarding the topic of context-specific quandaries for the special issue on ethical quandaries when delivering integrated primary care. The current author provides brief reflections on each article.

Ethical and effectiveness considerations with primary care behavioral health research in the medical home.

Integrated primary care research in the Patient-Centered Medical Home (PCMH) presents unique challenges not found in other behavioral health or medical care settings. The PCMH service delivery principles and supporting systems are designed to maximize quality and outcomes of care while controlling health care costs. Conducting ethical research in this setting requires following processes and procedures established by federal statutes that threaten to disrupt this delicate balance. In addition, clinical researchers must consider the ethical requirements and guidance from their respective professional organizations to ensure they adhere to guidelines for conducting ethical research and practice. Given the setting, there is a high likelihood researchers from various disciplines who may adhere to different ethical standards will be collaborating. We present a case example of an ethical concern to illustrate the tension between research and clinical care, discuss federal and professional research guidelines, and propose recommendations for balancing ethical and effective research and clinical care in integrated primary care research in the PCMH.

Primary-care provider reflections on research and training from special issue on ethical quandaries when delivering integrated primary care.

Comments on the articles by Goodie, Kanzler, Hunter, Glotfelter, & Bodart, (see record 2013-11498-012), and Reitz, Simmons, Runyan, Hodgson, & Carter-Henry(see record 2013-11498-013), regarding the topic of research and trainng for the special issue on ethical quandaries when delivering integrated primary care. The current author provides brief reflections on each article.