The nurse's role in a patient-centered approach for reducing COVID-19 vaccine hesitancy during pregnancy: An American Academy of Nursing consensus paper.

The evidence shows that COVID-19 vaccines can reduce the risks of poor pregnancy outcomes. Yet, reluctance to vaccinate remains high in pregnant populations. In this paper, we take a precision health and patient-centered approach to vaccine hesitancy. We adopted the society-to-cells vaccine hesitancy framework to identify society, community, family, individual, and physiologic factors contributing to COVID-19 vaccine hesitancy in pregnancy. Nurses are particularly well-suited to impact the factors associated with vaccine hesitancy. Because of their proximity to the patient, nurses are positioned to provide individualized, timely health information, and clinical guidelines to assist patients with decision-making related to vaccinations. Recommendations are provided to bolster nurses' engagement in precision health and patient-centered models of care to mitigate COVID-19 vaccine hesitancy in pregnancy.

Emergency department crowding: An examination of older adults and vulnerability.

Emergency departments in many nations worldwide have been struggling for many years with crowding and the subsequent provision of care in hallways and other unconventional spaces. While this issue has been investigated and analyzed from multiple perspectives, the ethical dimensions of the place of emergency department care have been underexamined. Specifically, the impacts of the place of care on patients and their caregivers have not been robustly explored in the literature. In this article, a feminist ethics and human geography framing is utilized to argue that care provision in open and unconventional spaces in the emergency department can be unethical, as vulnerability can be amplified by the place of care for patients and their caregivers. The situational and pathogenic vulnerability of patients can be heightened by the place of the emergency department and by the constraints to healthcare providers' capacity to promote patient comfort, privacy, communication, and autonomy in this setting. The arrangements of care in the emergency department are of particular concern for older adults given the potential increased risks for vulnerability in this population. As such, hallway healthcare can reflect the normalized inequities of structural ageism. Recommendations are provided to address this complicated ethical issue, including making visible the moral experiences of patients and their caregivers, as well as those of healthcare providers in the emergency department, advocating for a systems-level accounting for the needs of older adults in the emergency department and more broadly in healthcare, as well as highlighting the need for further research to examine how to foster autonomy and care in the emergency department to reduce the risk for vulnerabilities.

The experiences of nurses following seclusion or restraint use and immediate staff debriefing in inpatient mental health settings.

AIM: The aim of this study is to explore nurses' experiences of seclusion or restraint use and their participation in immediate staff debriefing in inpatient mental health settings. DESIGN: This research was conducted using a descriptive exploratory design and data were gathered through in-depth individual interviews. METHODS: The experiences of nurses following seclusion or restraint use and their participation in immediate staff debriefing were explored via teleconference, using a semi-structured interview guide. Reflexive thematic analysis was used to identify prevalent themes from the data. RESULTS: Interviews (n=10) were conducted with nurses from inpatient mental health wards in July 2020. Five themes emerged through the data analysis: (i) ensuring personal safety; (ii) grappling between the use of least-restrictive interventions and seclusion or restraint use; (iii) navigating ethical issues and personal reactions; (iv) seeking validation from colleagues and (v) attending staff debriefing based on previous experience. The themes were also analysed using Lazarus and Folkman's Transactional Model of Stress and Coping. CONCLUSION: Staff debriefing is a vital resource for nurses to provide and/or receive emotion- and problem-focused coping strategies. Mental health institutions should strive to establish supportive working environments and develop interventions based on the unique needs of nurses and the stressors they experience following seclusion or restraint use. PATIENT OR PUBLIC CONTRIBUTION: Nurses in both frontline and leadership roles were involved in the development and pilot test of the interview guide. The nurses who participated in the study were asked if they can be recontacted if clarification is needed during interview transcription or data analysis.

Professional responsibility, nurses, and conscientious objection: A framework for ethical evaluation.

Conscientious objections (CO) can be disruptive in a variety of ways and may disadvantage patients and colleagues who must step-in to assume care. Nevertheless, nurses have a right and responsibility to object to participation in interventions that would seriously harm their sense of integrity. This is an ethical problem of balancing risks and responsibilities related to patient care. Here we explore the problem and propose a nonlinear framework for exploring the authenticity of a claim of CO from the perspective of the nurse and of those who must evaluate such claims. We synthesized the framework using Rest's Four Component Model of moral reasoning along with tenets of the International Council of Nursing's (ICN) Code of Ethics for Nurses and insights from relevant ethics and nursing ethics literature. The resulting framework facilitates evaluating potential consequences of a given CO for all involved. We propose that the framework can also serve as an aid for nurse educators as they prepare students for practice. Gaining clarity about the sense in which the concept of conscience provides a defensible foundation for objecting to legally, or otherwise ethically, permissible actions, in any given case is critical to arriving at an ethical and reasonable plan of action.

Health care providers' ethical perspectives on waiver of final consent for Medical Assistance in Dying (MAiD): a qualitative study.

BACKGROUND: With the enactment of Bill C-7 in Canada in March 2021, people who are eligible for medical assistance in dying (MAiD), whose death is reasonably foreseeable and are at risk of losing decision-making capacity, may enter into a written agreement with their healthcare provider to waive the final consent requirement at the time of provision. This study explored healthcare providers' perspectives on honouring eligible patients' request for MAiD in the absence of a contemporaneous consent following their loss of decision-making capacity. METHOD: A critical qualitative methodology, using a feminist ethics theoretical lens with its focus on power and relationality, was used to examine how socio-political and environmental contexts influenced healthcare providers' moral agency and perspectives. Semi-structured interviews were conducted with 30 healthcare providers (13 physicians, six nurse practitioners, nine nurses and two social workers) from across Canada who provide MAiD-related care. RESULTS: Themes identified include; (1) balancing personal values and professional responsibilities, (2) anticipating strengths and limitations of the proposed waiver of final consent amendment, (3) experiencing ethical influences on decisions to enter into written agreements with eligible patients, (4) recognizing barriers to the enactment of MAiD in the absence of a contemporaneous consent and (5) navigating the potential for increased risks and burden. DISCUSSION: To our knowledge, this is the first study in Canada to explore healthcare providers' perspectives on waiving the final consent for MAiD using a written agreement. Most participants supported expanding eligible people's access to MAiD following loss of capacity, as they believed it would improve the patients' comfort and minimize suffering. However, the lack of patients' input at the time of provision and related ethical and legal challenges may impact healthcare providers' moral agency and reduce some patients' access to MAiD. Providers indicated they would enter into written agreements to waive final consent for MAiD on a case-by-case basis. This study highlights the importance of organizational, legal and professional support, adequate resources, clear policies and guidelines for the safety and wellbeing of healthcare providers and to ensure equitable access to MAiD.

The process of moral distress development: A virtue ethics perspective.

This theoretical paper proposes a new perspective to understand the moral distress of nurses more fully, using virtue ethics. Moral distress is a widely studied subject, especially with respect to the determination of its causes and manifestations. Increasing the theoretical depth of previous work using ethical theory, however, can create new possibilities for moral distress to be explored and analyzed. Drawing on more recent work in this field, we explicate the conceptual framework of the process of moral distress in nurses, proposed by Ramos et al., using MacIntyrean virtue ethics. Our analysis considers the experience of moral distress in the context of a practice, enabling the adaptation of this framework using virtue ethics. The adoption of virtue ethics as an ethical perspective broadens the understanding of the complexity of nurses' experiences of moral distress, since it is impossible to create a ready model that can cover all possibilities. Specifically, we describe how identity, social context, beliefs, and tradition shape moral discomfort, uncertainty, and sensitivity and how virtues inform moral judgments. Individuals, such as nurses, who are involved in a practice have a narrative history and a purpose (telos) that guide them in every step of the process, especially in moral judgment. It is worth emphasizing that the process described is supported by the formation of moral competence that, if blocked, can lead to moral distress and deprofessionalization. It is expected that nurses seek to achieve the internal good of their practice, which legitimizes their professional practice and supports them in moral decision-making, preventing moral distress.

Nurses' experiences of ethical responsibilities of care during the COVID-19 pandemic.

BACKGROUND: The COVID-19 pandemic has forced rapid and widespread change to standards of patient care and nursing practice, inevitably leading to unprecedented shifts in the moral conditions of nursing work. Less is known about how these challenges have affected nurses' capacity to meet their ethical responsibilities and what has helped to sustain their efforts to continue to care. RESEARCH OBJECTIVES: 1) To explore nurses' experiences of striving to fulfill their ethical responsibilities of care during the COVID-19 pandemic and 2) to explore what has fostered nurses' capacity to fulfill these responsibilities. RESEARCH DESIGN: A generic qualitative approach was used incorporating concepts coming from fundamental features of care. PARTICIPANTS: Twenty-four Canadian Registered Nurses from a variety of practice settings were interviewed. ETHICAL CONSIDERATIONS: After receiving ethics approval, signed informed consent was obtained before participants were interviewed. FINDINGS: Four themes were identified. 1) Challenges providing good care in response to sudden changes in practice. 2) Tensions in juggling the responsibility to prevent COVID-19 infections with other competing moral responsibilities. 3) Supports to foster nurses' capacity to meet their caring responsibilities. 4) The preservation of nurses' moral identity through expressions of gratitude and health improvement. DISCUSSION: Infection control measures and priorities set in response to the pandemic made at distant population and organizational levels impacted nurses who continued to try to meet the ideals of care in close proximity to patients and their families. Despite the challenges that nurses encountered, the care they received themselves enabled them to continue to care for others. Nurses benefited most from the moral communities they had with their colleagues and occasionally nurse leaders, especially when they were supported in a face-to-face manner.Conclusion: Moral community can only be sustained if nurses are afforded the working conditions that make it possible for them to support each other.

An examination of the moral habitability of resource-constrained obstetrical settings.

BACKGROUND: While there have been studies exploring moral habitability and its impact on the work environments of nurses in Western countries, little is known about the moral habitability of the work environments of nurses and midwives in resource-constrained settings. RESEARCH OBJECTIVE: The purpose of this research was to examine the moral habitability of the work environment of nurses and midwives in Ghana and its influence on their moral agency using the philosophical works of Margaret Urban Walker. RESEARCH DESIGN AND PARTICIPANTS: A critical moral ethnography was conducted through the analysis of interviews with 30 nurses and midwives, along with observation, and documentary materials. ETHICAL CONSIDERATIONS: After receiving ethics approval, signed informed consent was obtained from participants before data collection. RESULTS: Five themes were identified: (1) holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) scarcity of resources as limiting capacity to meet caring responsibilities; (3) gender and socio-economic inequities shaping the moral-social context of practice; (4) working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) surviving through adversity with renewed commitment and courage. DISCUSSION: The nurses and midwives were found to work in an environment that was morally uninhabitable and dominated by the scarcity of resources, overwhelming and incoherent moral responsibilities, oppressive conditions, and workplace violence. These situations constrained their moral agency and provoked suffering and distress. The nurses and midwives negotiated their practice and navigated through morally uninhabitable work environment by holding onto their moral values and commitments to childbearing women. CONCLUSION: Creating morally habitable workplaces through the provision of adequate resources and instituting interprofessional practice guidelines and workplace violence prevention policies may promote safe and ethical nursing and midwifery practice.

Postoperative Remote Automated Monitoring and Virtual Hospital-to-Home Care System Following Cardiac and Major Vascular Surgery: User Testing Study.

BACKGROUND: Cardiac and major vascular surgeries are common surgical procedures associated with high rates of postsurgical complications and related hospital readmission. In-hospital remote automated monitoring (RAM) and virtual hospital-to-home patient care systems have major potential to improve patient outcomes following cardiac and major vascular surgery. However, the science of deploying and evaluating these systems is complex and subject to risk of implementation failure. OBJECTIVE: As a precursor to a randomized controlled trial (RCT), this user testing study aimed to examine user performance and acceptance of a RAM and virtual hospital-to-home care intervention, using Philip's Guardian and Electronic Transition to Ambulatory Care (eTrAC) technologies, respectively. METHODS: Nurses and patients participated in systems training and individual case-based user testing at two participating sites in Canada and the United Kingdom. Participants were video recorded and asked to think aloud while completing required user tasks and while being rated on user performance. Feedback was also solicited about the user experience, including user satisfaction and acceptance, through use of the Net Promoter Scale (NPS) survey and debrief interviews. RESULTS: A total of 37 participants (26 nurses and 11 patients) completed user testing. The majority of nurse and patient participants were able to complete most required tasks independently, demonstrating comprehension and retention of required Guardian and eTrAC system workflows. Tasks which required additional prompting by the facilitator, for some, were related to the use of system features that enable continuous transmission of patient vital signs (eg, pairing wireless sensors to the patient) and assigning remote patient monitoring protocols. NPS scores by user group (nurses using Guardian: mean 8.8, SD 0.89; nurses using eTrAC: mean 7.7, SD 1.4; patients using eTrAC: mean 9.2, SD 0.75), overall NPS scores, and participant debrief interviews indicated nurse and patient satisfaction and acceptance of the Guardian and eTrAC systems. Both user groups stressed the need for additional opportunities to practice in order to become comfortable and proficient in the use of these systems. CONCLUSIONS: User testing indicated a high degree of user acceptance of Philips' Guardian and eTrAC systems among nurses and patients. Key insights were provided that informed refinement of clinical workflow training and systems implementation. These results were used to optimize workflows before the launch of an international RCT of in-hospital RAM and virtual hospital-to-home care for patients undergoing cardiac and major vascular surgery.

The medicalisation of the dying self: The search for life extension in advanced cancer.

Although many studies have previously examined medicalisation, we add a new dimension to the concept as we explore how contemporary oncological medicine shapes the dying self as predominantly medical. Through an analysis of multiple case studies collected within a comprehensive cancer centre in Ontario, Canada, we examine how people with late-stage cancer and their healthcare providers enacted the process of medicalisation through engaging in the search for oncological treatments, such as experimental drug trials, despite the incurability of their disease. The seven cases included 20 interviews with patients, family, physicians and nurses, the analysis of 30 documents and 5 hr of field observation. A poststructural perspective informed our study. We propose that searching for life extension enacts medicalisation by shaping the dying person afflicted with terminal cancer into new medical subjectivities that are knowledgeable, active, entrepreneurial and curative. Participants initially took up medical thinking from the formal oncology system, but then began to apply and internalise medical rationalities to alter their personhood, thereby generating new curative possibilities for themselves. For people seeking life extension, the embodied and day-to-day experiences of suffering and being close to death became expressed and moderated in fundamentally medicalised terms.

Relational influences on experiences with assisted dying: A scoping review.

BACKGROUND: Family members and healthcare providers play an integral role in a person's assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers. ETHICAL CONSIDERATIONS: Ethics approval was not required to conduct this review. AIM: This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent. METHODS: A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis. RESULTS: Five key themes on the influences of family members' and healthcare providers' experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death. CONCLUSION: The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each other's experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families' and healthcare providers' needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.

Advance care planning with chronically ill patients: A relational autonomy approach.

Advance care planning is a process that encourages people to identify their values, to reflect upon the meanings and consequences of serious illness, to define goals and preferences for future medical treatment and care, and to discuss these goals with family and health-care providers. Advance care planning is especially important for those who are chronically ill, as patients and their families face a variety of complex healthcare decisions. Participating in advance care planning has been associated with improved outcomes; yet, despite over 25 years of public awareness campaigns, research, and interventions developed to increase participation, advance care planning completion rates for people with chronic illnesses are no different than those in the general public (approximately 25%). Advance care planning has traditionally used an individualistic approach to autonomy, which puts forward an understanding of agents as independent, rational and self-interested persons. Because this individualistic approach has been largely unsuccessful in improving advance care planning uptake, a re-examination of the philosophical underpinnings of this practice and an exploration of alternative frameworks is warranted. In offering this exploration, we briefly outline two current perspectives on autonomy: the individualistic view and the relational view as articulated by feminist philosophers. Using a critical examination of the theoretical and empirical work on this topic, we argue that the individualistic view of autonomy does not sufficiently capture the relational and social complexities of the decision-making process of advance care planning. To offer a counterpoint, we examine the relational view of autonomy and suggest that this perspective is better aligned with the process of advance care planning. Specifically, we demonstrate that a relational model of autonomy is well suited to exploring advance care planning for four main reasons: (1) it recognizes the importance of relationships, (2) it reflects the fluctuating nature of autonomy in chronic illness, (3) it recognizes vulnerability, and (4) it is consonant with empirical work examining the advance care planning process.

The advocacy role of nurses in cardiopulmonary resuscitation.

BACKGROUND: The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation. RESEARCH OBJECTIVE: To explore what the nurse's advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain). RESEARCH DESIGN: An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data. PARTICIPANTS: Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5). ETHICAL CONSIDERATIONS: Approval was obtained from the Basque Country Clinical Research Ethics Committee. FINDINGS: Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns. DISCUSSION: The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses' advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team. CONCLUSION: This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians.

Invisibility of the self: Reaching for the telos of nursing within a context of moral distress.

Many studies have examined clinical and institutional moral problems in the practice of nurses that have led to the experience of moral distress. The causes and implications of moral distress in nurses, however, have not been understood in terms of their implications from the perspective of virtue ethics. This paper analyzes how nurses reach for the telos of their practice, within a context of moral distress. A qualitative case study was carried out in a private hospital in Brazil. Observation and semi-semistructured interviews were conducted with 13 nurse participants. With the aid of ATLAS.ti software, the data were analyzed by using thematic content analysis using virtue ethics to theorize the findings. These nurses experienced a loss of their nursing identity as they encountered an ambiguous telos and the domination of institutional values. In their reach for the telos of their practice, nurses found an environment permeated by ethical challenges, which not only created moral distress but also created professional invisibility, a phenomenon referred to as 'invisibility of the self'.

[Presence of relatives during cardiopulmonary resuscitation: Perspectives of health professionals, patients and family in the Basque Country]. / Presencia de familiares durante la reanimación cardiopulmonar: perspectivas de pacientes, familiares y profesionales de la salud en el País Vasco.

OBJECTIVE: To determine the perception of nurses, doctors, patients and family or relatives being present during cardiopulmonary resuscitation (CPR) in adult patients. DESIGN: A qualitative exploratory study and thematic analysis were developed. SITE: Primary Care, Hospital Care and Emergency Service of the Basque Health Service. PARTICIPANTS: The selection of the participants was made through intentional sampling. Four focus groups were developed: one of patients and family, 2 of nurses, and one of physicians. METHOD: Thematic analysis was performed. Triangulation techniques were used between investigators and investigator-participant member. The Open code 4.1 statistics software was used. RESULTS: Three significant categories were identified: the impact on the family; the weight of ethical and legal responsibility; power, place of death, and cultural assumptions. CONCLUSIONS: CPR is a social construct influenced by values which are situated in specific socio-cultural contexts. In this study, patients and family members describe the fear and resistance to being present during CPR. Health professionals consider that their decision is complex, and each case must be assessed independently, and patients and relatives must be integrated into decision-making. Future research should explore in greater depth the subjective experience of relatives who have witnessed CPR and the impact of contextual and sociocultural elements from the perspectives of relatives.

Instrumentalisation of the health system: An examination of the impact on nursing practice and patient autonomy.

Most current management systems of healthcare institutions correspond to a model of market ethics with its demands of competitiveness. This approach has been called managerialism and is couched in terms of much-needed efficiencies and effective management of budgetary constraints. The aim of this study was to analyse the decision-making of nurses through the impact of health institution management models on clinical practice. Based on Foucault's ethical theory, a qualitative study was conducted through a discourse analysis of the nursing records in a hospital unit. The results revealed that the health institution standardises health care practice, which has an impact on professional and patient autonomy as it pertains to decision-making. The results of this research indicate that resistance strategies in the internal structures of health organisations can replace the normalisation and instrumentalisation of professional practice aimed at promoting patient self-determination.

Nurses' narratives of moral identity: Making a difference and reciprocal holding.

BACKGROUND: Explicating nurses' moral identities is important given the powerful influence moral identity has on the capacity to exercise moral agency. RESEARCH OBJECTIVES: The purpose of this study was to explore how nurses narrate their moral identity through their understanding of their work. An additional purpose was to understand how these moral identities are held in the social space that nurses occupy. RESEARCH DESIGN: The Registered Nurse Journal, a bimonthly publication of the Registered Nurses' Association of Ontario, Canada, features a regular column entitled, 'In the End … What Nursing Means to Me …' These short narratives generally include a story of an important moment in the careers of the authors that defined their identities as nurses. All 29 narratives published before June 2015 were analysed using a critical narrative approach, informed by the work of Margaret Urban Walker and Hilde Lindemann, to identify a typology of moral identity. Ethical considerations: Ethics approval was not required because the narratives are publicly available. FINDINGS: Two narrative types were identified that represent the moral identities of nurses as expressed through their work: (1) making a difference in the lives of individuals and communities and (2) holding the identities of vulnerable individuals. DISCUSSION: Nurses' moral identities became evident when they could see improvement in the health of patients or communities or when they could maintain the identity of their patients despite the disruptive forces of illness and hospitalization. In reciprocal fashion, the responses of their patients, including expressions of gratitude, served to hold the moral identities of these nurses. CONCLUSION: Ultimately, the sustainability of nurses' moral identities may be dependent on the recognition of their own needs for professional satisfaction and care in ways that go beyond the kind of acknowledgement that patients can offer.

Examining the relationship between therapeutic self-care and adverse events for home care clients in Ontario, Canada: a retrospective cohort study.

BACKGROUND: In an era of a rapidly aging population who requires home care services, clients must possess or develop therapeutic self-care ability in order to manage their health conditions safely in their homes. Therapeutic self-care is the ability to take medications as prescribed and to recognize and manage symptoms that may be experienced, such as pain. The purpose of this research study was to investigate whether therapeutic self-care ability explained variation in the frequency and types of adverse events experienced by home care clients. METHODS: A retrospective cohort design was used, utilizing secondary databases available for Ontario home care clients from the years 2010 to 2012. The data were derived from (1) Health Outcomes for Better Information and Care; (2) Resident Assessment Instrument-Home Care; (3) National Ambulatory Care Reporting System; and (4) Discharge Abstract Database. Descriptive analysis was used to identify the types and prevalence of adverse events experienced by home care clients. Logistic regression analysis was used to examine the association between therapeutic self-care ability and the occurrence of adverse events in home care. RESULTS: The results indicated that low therapeutic self-care ability was associated with an increase in adverse events. In particular, logistic regression results indicated that low therapeutic self-care ability was associated with an increase in clients experiencing: (1) unplanned hospital visits; (2) a decline in activities of daily living; (3) falls; (4) unintended weight loss, and (5) non-compliance with medication. CONCLUSIONS: This study advances the understanding about the role of therapeutic self-care ability in supporting the safety of home care clients. High levels of therapeutic self-care ability can be a protective factor against the occurrence of adverse events among home care clients. A clear understanding of the nature of the relationship between therapeutic self-care ability and adverse events helps to pinpoint the areas of home care service delivery required to improve clients' health and functioning. Such knowledge is vital for informing health care leaders about effective strategies that promote therapeutic self-care, as well as providing evidence for policy formulation in relation to risk mitigation in home care.

The "Conflicted Dying": The Active Search for Life Extension in Advanced Cancer Through Biomedical Treatment.

Using a poststructural perspective, we examine the subjectivities that are produced when advanced cancer patients seek life extension through biomedical treatments. Seven case studies were developed that included 20 interviews with patients, family, nurses, and physicians recruited from a tertiary hospital in Canada, 30 documents, and 5 hours of participant observation. We identify seven types of subjectivity: (a) the Desperate Subject, (b) the Cancer Expert Subject, (c) the Proactive Subject, (d) the Productive Subject, (e) the Mistrusting Subject, (f) the Model Patient Subject, and (g) the Suffering Subject. We characterize the "conflicted dying," a contemporary figure who holds multiple perspectives about seeking curative treatment despite the acknowledgment of death. Using active strategies to gain access to treatment, this figure resists traditional arrangements of power/knowledge established by health care providers. We suggest that the search for life extension is a process of shaping the self to fit certain aesthetical traits associated with surviving cancer.