Organizational Virtue Ethics and Moral Distress among Healthcare Workers.

AbstractMoral distress is traditionally defined as situations where one knows the right thing to do but external constraints make it nearly impossible to pursue the right course of action. Many interventions to mitigate moral distress focus on making healthcare workers more resilient or courageous in the face of adverse circumstances. While these "virtue cultivation" responses might be valuable traits for individuals, I want to argue that cultivating virtue is at best an incomplete strategy for dealing with moral distress in an organizational setting. The individualistic character of these approaches ignores how an organization's policies may be contributing to many morally distressing situations. I will argue that resources from the virtue tradition can still play a valuable theoretical role in addressing moral distress in healthcare settings if we transpose them to the organizational level. The policies of a hospital or healthcare institution can be seen as virtuous to the degree that they further the organization's goals of medicine. Organizational virtue ethics can then illuminate the issue of moral distress in healthcare organizations. If an organization's policies contribute to its members suffering from moral distress, then that policy may well inhibit the organization from carrying out its mission of providing excellent healthcare. Organizations should respond to moral distress and seek ways to mitigate if not eliminate it.

The misperception of organizational racial progress toward diversity, equity, and inclusion.

Despite a checkered racial history, people in the United States generally believe the nation has made steady, incremental progress toward achieving racial equality. In this article, we investigate whether this U.S. racial progress narrative will extend to how the workforce views the effectiveness of organizational efforts surrounding diversity, equity, and inclusion. Across three studies (N = 1,776), we test whether Black and White U.S. workers overestimate organizational racial progress in executive representation. We also examine whether these misperceptions, surrounding organizational progress, drive misunderstandings regarding the relative ineffectiveness of common organizational diversity policies. Overall, we find evidence that U.S. workers largely overestimate organizational racial progress, believe that organizational progress will naturally improve over time, and that these misperceptions of organizational racial progress may drive beliefs in the effectiveness of diversity, equity, and inclusion policies. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Changes in maternity care policies and practices that support breastfeeding as measured by the Ten Steps to Successful Breastfeeding - United States, 2018-2022.

BACKGROUND: Experiences during the birth hospitalization affect a family's ability to establish and maintain breastfeeding. The Ten Steps to Successful Breastfeeding (Ten Steps) describe evidence-based hospital policies and practices shown to improve breastfeeding outcomes. We aim to describe hospitals' implementation of the Ten Steps, changes over time, and hospitals' implementation of a majority (≥ 6) of the Ten Steps by hospital characteristics and state. METHODS: The biennial Maternity Practices in Infant Nutrition and Care (mPINC) survey assesses all hospitals in the United States (including the District of Columbia and territories) that routinely provide maternity care services. We analyzed data from 2018, 2020, and 2022 survey cycles to describe trends in the prevalence of hospitals implementing maternity care policies and practices that are consistent with the Ten Steps. Differences were calculated using the absolute difference in percentage-points between 2018 and 2022. RESULTS: Between 2018 and 2022, the percentage of hospitals that implemented Step 2: Staff Competency and Step 5: Support Mothers with Breastfeeding increased 12 and 8 percentage points, respectively. The percentage of hospitals that implemented Step 6: Exclusive Breastfeeding Among Breastfed Infants was 7 percentage points lower in 2022 than 2018. Implementation of the remaining seven steps did not change by more than 5 percentage points in either direction between 2018 and 2022. Nationally, the percentage of hospitals that implemented ≥ 6 of the Ten Steps increased from 44.0% in 2018 to 51.1% in 2022. Differences were seen when comparing implementation of ≥ 6 of the Ten Steps by hospital characteristics including state, hospital size, and highest level of neonatal care offered. CONCLUSIONS: Nationally, maternity care policies and practices supportive of breastfeeding continued to improve; however, certain practices lost progress. Differences in implementation of the Ten Steps were observed across states and by certain hospital characteristics, suggesting more work is needed to ensure all people receive optimal breastfeeding support during their delivery hospitalization.

"Our program manager is a woman for the first time": perceptions of health managers on what workplace policies and practices exist to advance women's career progression in the health sector in Kenya.

BACKGROUND: Existing evidence suggests that organisation-level policies are important in enabling gender equality and equity in the workplace. However, there is little research exploring the knowledge of health sector employees on whether policies and practices to advance women's career progression exist in their organisations. In this qualitative study, we explored the knowledge and perspectives of health managers on which of their organisations' workplace policies and practices contribute to the career advancement of women and their knowledge of how such policies and practices are implemented and monitored. METHODS: We employed a purposive sampling method to select the study participants. The study adopted qualitative approaches to gain nuanced insights from the 21 in-depth interviews and key informant interviews that we conducted with health managers working in public and private health sector organisations. We conducted a thematic analysis to extract emerging themes relevant to advancing women's career progression in Kenya's health sector. RESULTS: During the interviews, only a few managers cited the policies and practices that contribute to women's career advancement. Policies and practices relating to promotion and flexible work schedules were mentioned most often by these managers as key to advancing women's career progression. For instance, flexible work schedules were thought to enable women to pursue further education which led to promotion. Some female managers felt that women were promoted to leadership positions only when running women-focused programs. There was little mention of capacity-building policies like training and mentorship. The health managers reported how policies and practices are implemented and monitored in general, however, they did not state how this is done for specific policies and practices. For the private sector, the health managers stated that implementation and monitoring of these policies and practices is conducted at the institutional level while for the public sector, this is done at the national or county level. CONCLUSIONS: We call upon health-sector organisations in Kenya to offer continuous policy sensitisation sessions to their staff and be deliberate in having supportive policies and other pragmatic interventions beyond policies such as training and mentorship that can enable women's career progression.

Association of institutional masking policies with healthcare-associated SARS-CoV-2 infections in Swiss acute care hospitals during the BA.4/5 wave (CH-SUR study): a retrospective observational study.

BACKGROUND: In the initial phase of the SARS-CoV-2 pandemic, masking has been widely accepted in healthcare institutions to mitigate the risk of healthcare-associated infection. Evidence, however, is still scant and the role of masks in preventing healthcare-associated SARS-CoV-2 acquisition remains unclear.We investigated the association of variation in institutional mask policies with healthcare-associated SARS-CoV-2 infections in acute care hospitals in Switzerland during the BA.4/5 2022 wave. METHODS: SARS-CoV-2 infections in hospitalized patients between June 1 and September 5, 2022, were obtained from the "Hospital-based surveillance of COVID-19 in Switzerland"-database and classified as healthcare- or community-associated based on time of disease onset. Institutions provided information regarding institutional masking policies for healthcare workers and other prevention policies. The percentage of healthcare-associated SARS-CoV-2 infections was calculated per institution and per type of mask policy. The association of healthcare-associated SARS-CoV-2 infections with mask policies was tested using a negative binominal mixed-effect model. RESULTS: We included 2'980 SARS-CoV-2 infections from 13 institutions, 444 (15%) were classified as healthcare-associated. Between June 20 and June 30, 2022, six (46%) institutions switched to a more stringent mask policy. The percentage of healthcare-associated infections subsequently declined in institutions with policy switch but not in the others. In particular, the switch from situative masking (standard precautions) to general masking of HCW in contact with patients was followed by a strong reduction of healthcare-associated infections (rate ratio 0.39, 95% CI 0.30-0.49). In contrast, when compared across hospitals, the percentage of health-care associated infections was not related to mask policies. CONCLUSIONS: Our findings suggest switching to a more stringent mask policy may be beneficial during increases of healthcare-associated SARS-CoV-2 infections at an institutional level.

Hospital policy of tranexamic acid to reduce transfusion in major non-cardiac surgery (TRACTION): protocol for a phase IV randomised controlled trial.

INTRODUCTION: Tranexamic acid (TXA) is an inexpensive and widely available medication that reduces blood loss and red blood cell (RBC) transfusion in cardiac and orthopaedic surgeries. While the use of TXA in these surgeries is routine, its efficacy and safety in other surgeries, including oncologic surgeries, with comparable rates of transfusion are uncertain. Our primary objective is to evaluate whether a hospital-level policy implementation of routine TXA use in patients undergoing major non-cardiac surgery reduces RBC transfusion without increasing thrombotic risk. METHODS AND ANALYSIS: A pragmatic, registry-based, blinded, cluster-crossover randomised controlled trial at 10 Canadian sites, enrolling patients undergoing non-cardiac surgeries at high risk for RBC transfusion. Sites are randomised in 4-week intervals to a hospital policy of intraoperative TXA or matching placebo. TXA is administered as 1 g at skin incision, followed by an additional 1 g prior to skin closure. Coprimary outcomes are (1) effectiveness, evaluated as the proportion of patients transfused RBCs during hospital admission and (2) safety, evaluated as the proportion of patients diagnosed with venous thromboembolism within 90 days. Secondary outcomes include: (1) transfusion: number of RBC units transfused (both at a hospital and patient level); (2) safety: in-hospital diagnoses of myocardial infarction, stroke, deep vein thrombosis or pulmonary embolism; (3) clinical: hospital length of stay, intensive care unit admission, hospital survival, 90-day survival and the number of days alive and out of hospital to day 30; and (4) compliance: the proportion of enrolled patients who receive a minimum of one dose of the study intervention. ETHICS AND DISSEMINATION: Institutional research ethics board approval has been obtained at all sites. At the completion of the trial, a plain language summary of the results will be posted on the trial website and distributed in the lay press. Our trial results will be published in a peer-reviewed scientific journal. TRIAL REGISTRATION NUMBER: NCT04803747.

Diverse perspectives on unit-level nurse staffing ratios in medical-surgical units: A Delphi policy analysis.

BACKGROUND: Appropriate staffing is essential to acute care delivery. Staffing ratio policy generates controversy. PURPOSE: This study examines perspectives on unit-level nurse-to-patient ratio policy in adult medical-surgical units. METHOD: Delphi methodology uses an invited diverse panel to analyze a policy's effects. Panelists completed iterative surveys about the impact they expect from unit-level ratio policy. FINDINGS: Panelists demonstrated moderate agreement that the proposed policy could increase staffing levels, decrease patient length of stay, and reduce nurse attrition. Other potential outcomes included reducing staffing in units above the minimum and increasing short-term costs. Panelists agreed that the policy could increase patient safety and nurse satisfaction and did not agree about the effect on long-term cost and innovation. Panelists also anticipated a mostly positive effect on patients and nurses. DISCUSSION: Policies that set unit-level nurse-to-patient ratios offer a potential strategy to improve medical-surgical staffing. Policy design should consider the range of expected outcomes.

Initial leadership concerns and availability of tobacco cessation services moderate changes in employee-reported concerns about tobacco-free workplace policy implementation over time.

Tobacco-free workplace policies (TFWPs) are underused evidence-based interventions that reduce the elevated use of tobacco among substance use treatment center (SUTC) employees and patients. SUTC employees' anticipated concerns about stakeholder pushback are barriers to TFWP adoption. Examination of discrepancies between anticipated and actualized employee-reported TFWP concerns arising from coworkers, patients, and community members in the context of leadership concerns and tobacco cessation care availability for employees may inform strategies to increase TFWP uptake. This study analyzed changes in employee-reported TFWP concerns from before to after a comprehensive tobacco-free workplace intervention that included TFWP implementation, using Chi-square/Fisher's exact tests. Preimplementation leadership policy concerns and tobacco cessation care availability were examined as moderators in generalized linear mixed models. Overall, 452 employees and 13 leaders provided data from 13 SUTCs collectively serving >82 000 patients annually. Results revealed significant decreases over time in employee-reported concerns about TFWP resistance from coworkers. Moderation analyses indicated that employee-anticipated concerns from coworkers and patients, respectively, were less likely to be actualized in SUTCs where leadership endorsed preimplementation TFWP concerns, whereas employee-reported patient concerns rose over time in SUTCs where leadership had no initial implementation concerns. Additionally, employee-anticipated concerns from coworkers were overestimated in SUTCs that did not offer tobacco cessation care to employees. Results supporting the nonactualization of anticipated employee concerns following TFWP implementation can be used to engage other SUTCs for TFWP adoption. Furthermore, moderation effects may suggest that center characteristics translate to greater attention to rollout, ultimately enhancing TFWP stakeholder acceptance.

Substance use treatment center (SUTC) employees and patients use tobacco at elevated rates and suffer disproportionately from tobacco-related diseases. The implementation of a tobacco-free workplace policy (TFWP) can reduce tobacco use disparities in this setting. However, employee concerns about TFWPs are often a deterrent to their adoption. This study assessed how employee-reported concerns changed over time and whether these changes differed based on center characteristics like center leadership concerns about the TFWP and availability of tobacco cessation services for employees. Overall, the most common employee-reported concerns were those arising from patients, followed by coworkers and community members throughout policy implementation. Results demonstrated that anticipated concerns from coworkers decreased over time in all SUTCs. Furthermore, TFWP concerns from coworkers and patients were overestimated by employees at centers wherein leadership had concerns about TFWP implementation, whereas patient concerns were underestimated at centers where leadership had no preimplementation concerns. Finally, employee-anticipated concerns from coworkers were overestimated in SUTCs without tobacco cessation care for employees. Findings suggest that employees may overestimate concerns/complaints from various stakeholders based on organizational factors. This information may be used to engage additional SUTCs in TFWP implementation by alleviating employee concerns about policy adoption.

Interprofessional reconstruction of a policy for academic advancement: The evolution and evaluation of scholarship for today, tomorrow, and beyond.

Within higher education, scholarship is narrowly and inconsistently defined, limiting recognition of evolving faculty expectations, particularly for nursing faculty. At this academic medical center, a campus-wide, multi-school, academic advancement policy was achieved with a broader definition of scholarship that included: peer-reviewed publication of federally funded research, as well as innovation in curriculum development, teaching methodology, community engagement, safety and quality improvement, clinical practice, and health policy that would be applicable to tenure and non-tenure track faculty. The background, process, and outcomes of developing an expanded definition of scholarship that encompasses new and evolving areas of scholarship for a reconstructed academic personnel policy is presented. Beginning with a literature review and surveys of other schools' policies, we describe how a campus-wide working group ensured consensus and acceptance of the new policy. Upon approval of the reconstructed document, guidelines for implementation were widely disseminated through training workshops and discussions, integration into new faculty orientation, and faculty development programs. We share our process, outcomes, and lessons learned believing this information to be useful to other institutions engaged in review and revision of their promotion and tenure processes to align with the increasing expectations of nursing faculty of today and tomorrow.

Understanding lactation policies and resources across a university system: survey and document review.

BACKGROUND: In the U.S., employees often return to work within 8-12 weeks of giving birth, therefore, it is critical that workplaces provide support for employees combining breastfeeding and work. The Affordable Care Act requires any organization with more than 50 employees to provide a space other than a restroom to express breastmilk and a reasonable amount of time during the workday to do so. States and worksites differ in the implementation of ACA requirements and may or may not provide additional support for employees combining breastfeeding and work. The purpose of this study was to conduct an analysis of the policies and resources available at 26 institutions within a state university system to support breastfeeding when employees return to work after giving birth. METHODS: Survey data was collected from Well-being Liaisons in the human resources departments at each institution. In addition, we conducted a document review of policies and online materials at each institution. We used univariate statistics to summarize survey results and an inductive and deductive thematic analysis to analyze institutional resources available on websites and in policies provided by the liaisons. RESULTS: A total of 18 (65.3%) liaisons participated in the study and revealed an overall lack of familiarity with the policies in place and inconsistencies in the resources offered to breastfeeding employees across the university system. Only half of the participating liaisons reported a formal breastfeeding policy was in place on their campus. From the document review, six major themes were identified: placing the burden on employees, describing pregnancy or postpartum as a "disability," having a university-specific policy, inclusion of break times for breastfeeding, supervisor responsibility, and information on lactation policies. CONCLUSION: The review of each institution's online resources confirmed the survey findings and highlighted the burden placed on employees to discover the available resources and advocate for their needs. This paper provides insight into how institutions support breastfeeding employees and provides implications on strategies to develop policies at universities to improve breastfeeding access for working parents.

Social Capital as a Framework to Address Organizational Climate Change Policy.

PURPOSE: To examine state Area Agencies on Aging (AAAs) in Pennsylvania for services they provide to older adults regarding extreme events and how readiness can be captured through social networks and policies at the local, state, and federal levels. METHOD: Using an online survey, 79% of AAA directors answered questions describing perceptions and actions related to social capital and its influence on policy. RESULTS: AAAs acknowledged weather/temperature changes impact the need to prepare for common scenarios of extreme weather, temperature, and flooding. AAAs reported major social connections with county government and one state agency, with limited connections with federal agencies. CONCLUSION: Multiple opportunities exist for AAAs to consider climate change in expansion efforts, specifically regarding health care. Geriatric nurses can play a key role in expansion, advocacy, and policy development for AAAs that serve older adults in the context of climate change. [Journal of Gerontological Nursing, 50(6), 11-15.].

The role of regulatory policies in organizational culture: Insights from the education industry.

On February 26, 2018 and July 24, 2021, the Chinese government respectively issued two significant regulatory policies to address the problems caused by off-campus training institutions in terms of students' extra-curricular and family financial burdens. These policies have had a tremendous and far-reaching impact on the off-campus training industry in China. With the help of these two events, we explored the role of industry-level regulatory policies in shaping and forming organizational culture. This paper adopts a text analysis method, combined with the dimensions of the Denison Organizational Culture Survey (DOCS) and MAXQDA 18 software, to obtain data on corporate culture. Then, the approaches of regression discontinuity in time (RDiT) and regression discontinuity (RD) designs with multiple cutoffs are used to estimate the policy treatment effect. This empirical research suggests that regulatory policies have a significant impact on corporate culture. Moreover, regulatory policies of varying degrees of strictness have differential effects on different dimensions of corporate culture. The research findings contribute to the theories of corporate culture and can guide enterprises to evaluate the impact of policies on corporate culture more clearly, thereby enabling them to make wiser operation decisions.

The effects and benefits of a latent print AFIS deferral policy.

Forensic laboratories in the United States had an estimated backlog of 570,100 requests for all forensic services at the end of 2014. Latent print requests represented approximately 12% of that total backlog [1, NIJ 2019]. With ever-increasing demands and backlogs, a review of laboratory or section practices becomes vital to operations. Work process and business practice changes can increase efficiencies and result in the reduction of casework backlogs and turnaround times. The automated fingerprint identification system (AFIS) deferral policy implemented by the Latent Print Comparative Section (LPCS) of the Phoenix Police Department Laboratory Services Bureau (PPD LSB) was employed to address the latent print backlog. Five years of multiple AFIS request types were analyzed to demonstrate the positive effects and benefits of such policies, including a 26.32% decrease in turnaround time over the data collection and analysis period and a 90.96% reduction in backlogged requests for one year.

Medical management of early pregnancy loss with mifepristone and misoprostol in emergency departments compared to a Complex Family Planning office: Implementation of a COVID-19 institutional policy change.

OBJECTIVES: To evaluate the implementation of mifepristone and misoprostol for medical management of early pregnancy loss (EPL) in emergency departments (EDs) by comparing efficacy, complication, and follow-up rates for patients treated in EDs to the Complex Family Planning (CFP) outpatient office. STUDY DESIGN: In COVID-19's first wave, we expanded medical management of EPL to our EDs. This retrospective study evaluated 72 patients receiving mifepristone and misoprostol for EPL from April 1, 2020 to March 31, 2021, comparing treatment success, safety outcomes, and follow-up rates by location. RESULTS: Thirty-three (46%) patients received care in the ED and 39 (54%) at CFP. Treatment success was lower in EDs (23, 70%) compared to CFP (34, 87%), but after adjusting for insurance status and pregnancy type (miscarriage, uncertain viability, unknown location), this was not significant: adjusted odds ratio 0.48 (95% CI 0.13-1.81). More ED patients underwent emergent interventions (3 vs 0) including two emergent uterine aspirations, one uterine artery embolization, and two blood transfusions. Two cases were attributed to misdiagnosis (cesarean scar and cervical ectopic pregnancies interpreted as incomplete miscarriages) and one to guideline nonadherence. No complications occurred in the CFP group. Follow-up rates were over 80% in both groups. More ED patients engaged in telehealth follow-up (67% vs 18%, p ≤ 0.0001). CONCLUSIONS: In this small sample, we observed a trend toward less successful treatment in the ED compared to the CFP office. Both correctly making uncommon diagnoses and adhering to new guidelines presented implementation challenges. IMPLICATIONS: Implementing mifepristone and misoprostol for EPL in our EDs achieved lower rates of pregnancy resolution compared to outpatient management. Complex uncommon diagnoses and implementing new care pathways in EDs may have contributed to complications and highlighted opportunities for improvement. Additional studies are needed to further quantify safety outcomes for EPL management in EDs.

Consensus-Driven Recommendations to Support Physician Pregnancy, Adoption, Surrogacy, Parental Leave, and Lactation in Emergency Medicine.

The emergency department clinical environment is unique, and guidelines for promoting supportive and equitable workplace cultures ensure success and longevity for pregnant persons and parents in emergency medicine. There is paucity, variability, and dissatisfaction with current parental (historically referred to as maternity and paternity) leave policies. This paper describes the development of consensus-derived recommendations to serve as a framework for emergency departments across the country for incorporating family-friendly policies. Policies that foster a family-inclusive workplace by allowing for professional advancement without sacrificing personal values regardless of sex, gender, and gender identity are critical for emergency medicine recruitment and retention.

What are the effects of smoke-free and tobacco-free university campus policies, and how can they be assessed? A systematic review.

OBJECTIVE: This article looks at the evaluation of smoke-free (SF) and tobacco-free (TF) university campus policies that ban smoking (and often vaping) both indoors and outdoors. To assess the effectiveness of these policies, we performed a systematic literature review to answer the following questions: what is the effect of SF/TF policies on campus users' behaviors/norms/perceptions around smoking? Are the SF/TF policies an effective measure for reducing smoking among young adults? What methods and indicators can we use to assess the impact of SF/TF campus policies? What is the theoretical model underpinning the influence of SF/TF policies on the behavior of campus users? METHODS: Three databases (PubMed, Scopus, and Web of Science) were searched over the period from January 2005 to December 2022. The article selection process included 54 articles published in scientific journals that analyzed the post-implementation impact of SF/TF campus policies. The quality of these articles was analyzed using six ad hoc indicators based on the Critical Appraisal Skills Program checklist and Joanna Briggs Institute scoping tools. RESULTS: Most of the research on SF/TF campus policies has been conducted in the United States using quantitative methodologies. Most of these studies show that SF/TF policies reduce positive beliefs about smoking and its acceptability, influence smoking behavior (reducing smoking initiation and increasing the number of quits and quit attempts), and reduce exposure to passive smoking and pollution from cigarette butts. User acceptability of SF/TF policies is generally high. Limitations of SF/TF campus policies include difficulty for smokers to comply with them, persistence of passive smoking around campuses, and limited uptake of on-campus cessation support services provided to smokers. DISCUSSION: The various mediating and moderating variables identified in the literature have made it possible to propose a model of the potential influence of SF/TF policy on campus users, based on the theory of planned behavior. Based on this review, we provide health professionals and higher education institutions wishing to implement a SF/TF campus policy with a set of indicators that can serve to assess the impact of a SF/TF campus policy (attitudes, acceptability, beliefs, norms, exposure to passive smoking and pollution, changes in smoking behavior). CONCLUSION: Based on scientific evidence, the implementation of SF/TF campus policies in France is an important measure to help combat smoking in young adults.