"What guides us here?" Exploring community health nurses' experiences of moral distress

The concept of moral distress was first developed in the mid 1980’s by the American philosopher Dr. Andrew Jameton. Since then, moral distress has been studied in many health care practice settings and among various disciplines. However, moral distress among nurses in community health care settings has remained largely unexplored. Community health nurses (CHNs) work with clients, families, and communities with a variety of diverse care needs. Therefore, in this research I cast a wide net by asking a broad question, “What guides us here?” What guides nurses through the ethical landscape of community health nursing? The purpose of this research, then, is to explore CHNs experiences of everyday ethical issues and moral distress and identify educational opportunities for ongoing learning and support. To do this I used a narrative inquiry approach and interviewed 20 Canadian CHNs by phone. Based on my analysis of the data, categories of key ethical issues, themes, and educational needs were explored and identified. From the interview data, participants’ stories were then re-storied by me into meta-narratives. Nine meta-narratives, inspired by multiple-participant interview responses, were created as an end product of this study. The meta-narratives represent stories that are true to life in the details regarding situations that the CHNs reported from their nursing practice. At the same time, however, the meta-narratives do not describe any one situation; rather they reflect aspects of several stories combined. Thus, the meta-narratives offer protection of confidentiality, provide an evidence-based, detailed account of these experiences, and are educational resources for CHNs. I also designed and had participants evaluate an educational intervention in the form of a self-directed e-learning module (e-module). Based on the research findings, I offer recommendations for action to promote ethical nursing practice and support CHNs, which include implications for education, theory, research, and nursing practice. This research provides foundational knowledge about the ethical landscape of community health nursing in Canada, the everyday ethical issues faced, experiences of moral distress, and educational opportunities to support CHNs

Operational framework for rural hospitals during a pandemic

It is now evident that a second wave of the COVID-19 pandemic has developed. The unfortunate reality is that those in rural areas may be impacted the hardest. Ethical decision making may look the same for rural areas as urban areas, but this is far from accurate. This practice article is focused on why the challenges are different and how rural hospitals might manage their unique circumstances and constraints. A step-wise decision-making framework is also proposed

A practical approach to hospital visitation during a pandemic: Responding with compassion to unjustified restrictions

During the COVID-19 pandemic, evidence-based resources have been sought to support decision-making and strategically inform hospitals’ policies, procedures, and practices. While greatly emphasizing protection, most guiding documents have neglected to support and protect the psychosocial needs of frontline health care workers and patients and their families during provision of palliative and end-oflife care. Consequently, the stage has been set for increased anxiety, moral distress, and moral injury and extreme moral hazard. A family-centered approach to care has been unilaterally relinquished to a secondary and nonessential role during the current crisis. This phenomenon violates a foundational public health principle, namely, to apply the least restrictive means to achieve good for the many. Instead, there has been widespread adoption of utilitarian and paternalistic approaches. In many cases the foundational principles of palliative care have also been neglected. No circumstance, even a global public health emergency, should ever cause health care providers to deny their ethical obligations and human commitment to compassion. The lack of responsive protocols for family visitation, particularly at the end of life, is an important gap in the current recommendations for pandemic triage and contingency planning. A stepwise approach to hospital visitation using a tiered, standardized process for responding to emerging clinical circumstances and individual patients’ needs should be considered, following the principle of proportionality

Into the Grey Zone: Retired Nurses’ Reflections on Ethics in Canadian Nursing Practice

Context: Nurses are often hesitant to talk about ethical issues in their practice for many unique and valid reasons. What if the burden of risk was lifted upon retirement, even if just slightly? The purpose of this study was to explore retired nurses’ reflections on their experiences of ethical issues and decision making in various nursing practice settings throughout their careers and to glean recommendations for ethics in contemporary nursing practice. Methods: Data were collected via in-depth, individual, semi-structured interviews. Guided by an interpretive, descriptive approach, data were managed with NVivo v.11 and analyzed with an inductive, comparative, thematic approach. In northern Ontario, two nurse researchers co-interviewed eight retired nurses with decades of practice experience across diverse Canadian health care settings. Ethics approval was obtained through Lakehead University’s Research Ethics Board. Findings: Three themes emerged to address ethical issues in practice; these are creativity, resourcefulness, and a strong sense of community with other nurses. Further, the retired nurses’ collated reflections on ethics in practice are presented as the FIG model: Fellowship, Ingenuity, and Gumption. Conclusions: This study identifies ethical underpinnings that retired nurses have used to effectively respond to ethical issues in their practice. Those who are currently nursing, and nursing as a profession, may wish to recognize and retain these strategies in order to continue to deliver a high standard of quality, ethical care. Recommendations for practice, research, and education are offered.Contexte : Les infirmières hésitent souvent à parler des questions d’éthique dans leur pratique pour de nombreuses raisons uniques et valables. Et si le fardeau du risque était allégé à la retraite, ne serait-ce que légèrement? L’objectif de cette étude était d’explorer les réflexions des infirmières et infirmiers à la retraite sur leurs expériences des questions éthiques et de la prise de décision dans divers contextes de pratique infirmière tout au long de leur carrière et de glaner des recommandations sur l’éthique dans la pratique infirmière contemporaine. Méthodes : Les données ont été recueillies au moyen d’entretiens individuels semi-structurés approfondis. Guidées par une approche interprétative et descriptive, les données ont été gérées avec NVivo v.11 et analysées selon une approche inductive, comparative et thématique. Dans le nord de l’Ontario, deux infirmières chercheuses ont co-interviewé huit infirmières à la retraite ayant des décennies d’expérience de la pratique dans divers milieux de soins de santé canadiens. L’approbation éthique a été obtenue auprès du comité d’éthique de la recherche de l’Université Lakehead. Résultats : Trois thèmes ont émergé pour aborder les questions d’éthique dans la pratique : la créativité, l’ingéniosité et un fort sentiment de communauté avec les autres infirmières. De plus, les réflexions rassemblées par les infirmières à la retraite sur l’éthique dans la pratique sont présentées comme le modèle FIG : Fellowship, Ingenuity, and Gumption. Conclusions : Cette étude identifie les fondements éthiques que les infirmières à la retraite ont utilisés pour répondre efficacement aux questions éthiques dans leur pratique. Ceux qui sont actuellement infirmiers et infirmières en tant que profession pourraient souhaiter reconnaître et conserver ces stratégies afin de continuer à fournir des soins de qualité et éthiques. Des recommandations pour la pratique, la recherche et l’éducation sont proposées

Into the Grey Zone: Retired Nurses’ Reflections on Ethics in Canadian Nursing Practice

Context: Nurses are often hesitant to talk about ethical issues in their practice for many unique and valid reasons. What if the burden of risk was lifted upon retirement, even if just slightly? The purpose of this study was to explore retired nurses’ reflections on their experiences of ethical issues and decision making in various nursing practice settings throughout their careers and to glean recommendations for ethics in contemporary nursing practice. Methods: Data were collected via in-depth, individual, semi-structured interviews. Guided by an interpretive, descriptive approach, data were managed with NVivo v.11 and analyzed with an inductive, comparative, thematic approach. In northern Ontario, two nurse researchers co-interviewed eight retired nurses with decades of practice experience across diverse Canadian health care settings. Ethics approval was obtained through Lakehead University’s Research Ethics Board. Findings: Three themes emerged to address ethical issues in practice; these are creativity, resourcefulness, and a strong sense of community with other nurses. Further, the retired nurses’ collated reflections on ethics in practice are presented as the FIG model: Fellowship, Ingenuity, and Gumption. Conclusions: This study identifies ethical underpinnings that retired nurses have used to effectively respond to ethical issues in their practice. Those who are currently nursing, and nursing as a profession, may wish to recognize and retain these strategies in order to continue to deliver a high standard of quality, ethical care. Recommendations for practice, research, and education are offered.Contexte : Les infirmières hésitent souvent à parler des questions d’éthique dans leur pratique pour de nombreuses raisons uniques et valables. Et si le fardeau du risque était allégé à la retraite, ne serait-ce que légèrement? L’objectif de cette étude était d’explorer les réflexions des infirmières et infirmiers à la retraite sur leurs expériences des questions éthiques et de la prise de décision dans divers contextes de pratique infirmière tout au long de leur carrière et de glaner des recommandations sur l’éthique dans la pratique infirmière contemporaine. Méthodes : Les données ont été recueillies au moyen d’entretiens individuels semi-structurés approfondis. Guidées par une approche interprétative et descriptive, les données ont été gérées avec NVivo v.11 et analysées selon une approche inductive, comparative et thématique. Dans le nord de l’Ontario, deux infirmières chercheuses ont co-interviewé huit infirmières à la retraite ayant des décennies d’expérience de la pratique dans divers milieux de soins de santé canadiens. L’approbation éthique a été obtenue auprès du comité d’éthique de la recherche de l’Université Lakehead. Résultats : Trois thèmes ont émergé pour aborder les questions d’éthique dans la pratique : la créativité, l’ingéniosité et un fort sentiment de communauté avec les autres infirmières. De plus, les réflexions rassemblées par les infirmières à la retraite sur l’éthique dans la pratique sont présentées comme le modèle FIG : Fellowship, Ingenuity, and Gumption. Conclusions : Cette étude identifie les fondements éthiques que les infirmières à la retraite ont utilisés pour répondre efficacement aux questions éthiques dans leur pratique. Ceux qui sont actuellement infirmiers et infirmières en tant que profession pourraient souhaiter reconnaître et conserver ces stratégies afin de continuer à fournir des soins de qualité et éthiques. Des recommandations pour la pratique, la recherche et l’éducation sont proposées