Carol Pavlish

Background: Moral dilemmas and ethical conflicts occur in critical care. Negative consequences include misunderstandings, mistrust, patient and family suffering, clinician moral distress, and patient safety concerns. Providing an opportunity for team-based ethics assessments and planning could improve communication and reduce moral distress. Objectives: The aims of this study were to explore whether an early action ethics intervention affects intensive care unit (ICU) clinicians' moral distress, ethics self-efficacy, and perceptions of hospital climate and to compare nurses' and physicians' scores on moral distress, ethics self-efficacy, and ethical climate at 3 time points. Methods: Intensive care unit nurses and physicians were asked to complete surveys on moral distress, ethics self-efficacy, and ethical climate before implementing the ethics protocol in 6 ICUs. We measured responses to the same 3 surveys at 3 and 6 months after the protocol was used. Results: At baseline, nurses scored significantly higher than physicians in moral distress and significantly lower in ethics self-efficacy. Plot graphs revealed that nurses' and physicians' outcome scores trended toward one another. At 3 and 6 months post intervention, nurse and physician scores changed differently in moral distress and ethics self-efficacy. When examining nurse and physician scores separately over time, we found nurses' scores in moral distress and moral distress frequency decreased significantly over time and ethics self-efficacy and ethics climate increased significantly over time. Physicians' scores did not change significantly. Discussion: This study indicates that routine, team-based ethics assessment and planning opens a space for sharing information, which could decrease nurses' moral distress and increase their ethics self-efficacy. This, in turn, can potentially promote teamwork and reduce burnout.

As refugee populations continue to age in the United States, there is a need to prioritize screening for chronic illnesses, including cancer, and to characterize how social and cultural contexts influence beliefs about cancer and screening behaviors. This study examines screening rates and socio-cultural factors influencing screening among resettled refugee women from Muslim-majority countries of origin. A systematic and integrative review approach was used to examine articles published from 1980 to 2019, using PubMed, CINAHL, and PsycINFO. A total of 20 articles met the inclusion criteria. Cancer screening rates among refugee women are lower when compared to US-born counterparts. Social and cultural factors include religious beliefs about cancer, stigma, modesty and gender roles within the family context. The findings of this review, suggest that resettled refugee women underutilize preventive services, specifically mammography, Pap test and colonoscopy screening, and whose perceptions and behaviors about cancer and screening are influenced by social and cultural factors.

Background: Ethical conflicts complicate clinical practice and often compromise communication and teamwork among patients, families, and clinicians. As ethical conflicts escalate, patient and family distress and dissatisfaction with care increase and trust in clinicians erodes, reducing care quality and patient safety. Objective: To investigate the effectiveness of a proactive, team-based ethics protocol used routinely to discuss ethics-related concerns, goals of care, and additional supports for patients and families. Methods: In a pre-post intervention study in 6 intensive care units (ICUs) at 3 academic medical centers, the electronic medical records of 1649 patients representing 1712 ICU admissions were studied. Number and timing of family conferences, code discussions with the patient or surrogate, and ethics consultations; palliative care, social work, and chaplain referrals; and ICU length of stay were measured. Preintervention outcomes were compared with outcomes 3 and 6 months after the intervention via multivariate logistic regression controlled for patient variables. Results: The odds of receiving a family conference and a chaplain visit were significantly higher after the intervention than at baseline. The number of palliative care consultations and code discussions increased slightly at 3 and 6 months. Social work consultations increased only at 6 months. Ethics consultations increased at both postintervention time points. Length of ICU stay did not change. Conclusions: When health care teams were encouraged to communicate routinely about goals of care, more patients received needed support and communication barriers were reduced.

Background Critical care clinicians routinely encounter ethically complex situations. Ethical conflicts sometimes arise from different perspectives regarding goals of care and moral obligations. These conflicts contribute to providers’ moral distress and burnout and can erode trust between patients, families, and clinicians. Objectives To explore the most disturbing and most frequent types of ethically complex situations; compare clinicians’ perceptions of their own, each other’s, and shared moral obligations for providing quality care in these situations; and examine perceptions of communication and teamwork. Methods A national, web-based survey was made available to members of the American Association of Critical-Care Nurses and the Society for Critical Care Medicine. The survey included rank order, rating, and open-ended questions. Results Nurses and physicians ranked similarly the most frequent and disturbing ethical situations encountered during critical care practice. Nurses and physicians rated similarly physicians’ moral obligations, but their ratings of nurses’ moral obligations differed, with physicians giving lower ratings. Physicians also were more likely than nurses to report higher levels of trust (90.6% vs 66.8%) and more satisfaction with team communication (81.3% vs 66.9%). Narrative comments revealed embedded, entwined, and sometimes divergent expectations about moral obligations, which interfered with effective teamwork during ethically complex situations. Conclusions Teamwork in critical care would benefit from acknowledgment of and clear communication about role-specific, interdependent, and shared moral obligations. Opportunities for routine, team-based dialogue about ethical aspects of care and moral obligations could reduce role ambiguity and ethical conflicts.

Emerging adulthood refers to a distinct life stage between adolescence and adulthood, specifically from age 18 years to the mid to late 20s. Building on the work of Erik Erikson and Daniel Levinson in developmental psychology, Arnett (2004) first proposed emerging adulthood and defined five key attributes: identity exploration, instability, self-focus, feeling in-between, and possibilities. According to this theory, profound demographic shifts, social revolutions, and economic realities have resulted in a protracted developmental trajectory (Arnett, 2014; Blatterer, 2007).

Describing a long-term community-based action research project on improving health conditions for displaced persons in Rwanda and South Sudan, this practice note discusses human rights as a framework for improving people’s health. In the course of researching women’s health concerns, researchers learned that human rights violations were a major root cause of poor health among many displaced persons, and especially for women. Partnering with an international non-governmental organization (NGO), the American Refugee Committee, Congolese refugees in Rwanda, and returnees in South Sudan, researchers first explored local perceptions of human rights. Findings were presented to community members and incorporated into a culturally-nuanced health and human rights training programme. We offer lessons learned when working with community members and international partners to develop this community-based educational project on human rights. Primarily, we argue that human rights are intricately related to women’s health. We also suggest that human rights messages are best conceptualized with local concepts and best spoken by trusted community members such as community health workers. Human rights are conceptualized across cultural differences as an ongoing struggle for respect and fair treatment. Women’s experiences of human rights violations most often occur in the context of everyday life and lead to poor outcomes in women’s health. A rights-based framework could assist practitioners and organizations that aim to promote women’s health, development, and well-being.

OBJECTIVE: The aim of this study is to explore nurse leaders’ experiences working in ethically difficult situations and helping nurses cope with moral distress. BACKGROUND: Moral distress is associated with ethically complex situations where nurses feel voiceless and powerless. Moral distress can lead to disengagement, burnout, and decreased quality of care. METHODS: The critical incident technique was used to collect descriptions of ethically complex situations from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and subsequently counted. RESULTS: Participants noted affective, behavioral, cognitive, physical, and relational signs of moral distress. System-level factors along with team conflict and different perspectives were perceived to increase the probability of ethical conflicts. Key actions to address moral distress included acknowledging its presence, creating a culture of care, and increasing nurses’ resilience to difficult circumstances through education, support, and collaboration. CONCLUSIONS: On the basis of study findings, we created the SUPPORT model as an action guide for addressing moral distress.

OBJECTIVES: The aims of this study were to explore nurse leaders’ experiences with ethically difficult situations, perceptions about risk factors, and specific actions for ethical conflicts. BACKGROUND: Research indicates that nurses are reluctant to bring ethical concerns to nurse leaders for fear of creating trouble, and yet, nurse leaders are key figures in supporting ethics-minded clinicians and cultures. METHODS: The critical incident technique was used to collect descriptions from 100 nurse leaders in California. Responses were qualitatively coded, categorized, and counted. RESULTS: End-of-life situations accounted for the majority of incidents. Most situations had 3 to 4 ethical issues. Healthcare provider and system-level factors were perceived to increase the likelihood of ethical conflicts more often than family and patient factors. Respondents were more likely to identify leader actions that address specific situations rather than specify system-level actions addressing root causes of conflicts. CONCLUSIONS: Findings can be used to help leaders create ethics competencies, policies, and education.

Background Ethical conflicts, often leading to poor teamwork and moral distress, are very challenging to patients, patients’ families, and health care providers. A proactive approach to ethical conflicts may improve patient care outcomes. Objectives To examine acceptability and feasibility of an ethics screening and early intervention tool for use by nurses caring for critically ill patients. Methods Twenty-eight nurses in 2 medical centers applied the ethics screening tool to 55 patient situations. Nurses assessed situations for risk factors and early indicators of ethical conflicts and analyzed level of risk. At study completion, nurses participated in focus group discussions about the tool’s benefits and challenges. Frequency counts were performed on risk factors and early indicators of ethical conflicts. Content analysis was used on written explanations regarding high-, medium-, and low-risk situations and on focus group data. Results Older patients with multiple comorbid conditions and aggressive treatments were frequently assessed to be at risk for ethical conflicts. Nurses who witnessed patients’ suffering and deterioration were likely to initiate the screening process. The most prominent family risk factors included unrealistic expectations and adamancy about treatment. The most prominent early indicators were signs of patients’ suffering, unrealistic expectations, and providers’ own moral distress. High-risk situations averaged a greater number of risk factors and early indicators than did medium- and low-risk situations. Certain risk factors featured prominently in high-risk situations. Conclusions A phenomenon of shared suffering emerged from the study and signifies the importance of relational strategies such as routine family conferences and ethics consultation.