Moral Distress, Mattering, and Secondary Traumatic Stress in Provider Burnout: A Call for Moral Community.

Burnout incurs significant costs to health care organizations and professionals. Mattering, moral distress, and secondary traumatic stress are personal experiences linked to burnout and are byproducts of the organizations in which we work. This article conceptualizes health care organizations as moral communities-groups of people united by a common moral purpose to promote the well-being of others.

"Can you tell me why you made that choice?": A qualitative study of the influences on treatment decisions in advance care planning among adolescents and young adults undergoing bone marrow transplant.

Background: Adolescent and young adult advance care planning is beneficial in improving communication between patients, surrogates, and clinicians. The influences on treatment decisions among adolescents and young adults are underexplored in the literature.

Aim: The aim of this study was to explore and better understand the influences on decision-making for adolescent and young adult bone marrow transplant patients about future medical care.

Physicians' Perspectives on Adolescent and Young Adult Advance Care Planning The Fallacy of Informed Decision Making.

Advance care planning (ACP) is a process that seeks to elicit patients' goals, values, and preferences for future medical care. While most commonly employed in adult patients, pediatric ACP is becoming a standard of practice for adolescent and young adult patients with potentially life-limiting illnesses. The majority of research has focused on patients and their families; little attention has been paid to the perspectives of healthcare providers (HCPs) regarding their perspectives on the process and its potential benefits and limitations.

"Buying-In" and "Cashing-Out": Patients' Experience and the Refusal of Life-Prolonging Treatment.

Surgical "buy-in" is an "informal contract between surgeon and patient in which the patient not only consents to the operative procedure but commits to the post-operative surgical care anticipated by the surgeon." Surgeons routinely assume that patients wish to undergo treatment for operative complications so that the overall treatment course is "successful," as in the treatment of a post-operative infection. This article examines occasions when patients buy-in to a treatment course that carries risk of complication, yet refuse treatment when complications arise.

Holding Ashley (X): Bestowing Identity Through Caregiving in Profound Intellectual Disability.

The controversy over the so-called Ashley Treatment (AT), a series of medical procedures that inhibited both growth and sexual development in the body of a profoundly intellectually impaired girl, usually centers either on Ashley's rights, including a right to an intact, unaltered body, or on Ashley's parents' rights to make decisions for her. The claim made by her parents, that the procedure would improve their ability to care for her, is often dismissed as inappropriate or, at best, irrelevant. We argue, however, that caregiving is a central issue in the controversy, as Ashley's need for caregiving is a defining characteristic of her life.

What Should Physicians Do When They Disagree, Clinically and Ethically, with a Surrogate's Wishes?

When patients' surrogates and physicians disagree about the appropriateness of aggressive treatment in intensive care units (ICUs), physicians can experience surrogates' demands as sources of moral distress. This article addresses the virtues and communication strategies needed to respond appropriately in such situations. Specifically, we offer a framework and language that rely on moral community to facilitate common ground and alleviate moral distress.

Moral Agency, Moral Imagination, and Moral Community: Antidotes to Moral Distress.

Moral distress has been covered extensively in the nursing literature and increasingly in the literature of other health professions. Cases that cause nurses' moral distress that are mentioned most frequently are those concerned with prolonging the dying process. Given the standard of aggressive treatment that is typical in intensive care units (ICUs), much of the existing moral distress research focuses on the experiences of critical care nurses.

Fostering Nurses' Moral Agency and Moral Identity: The Importance of Moral Community.

It may be the case that the most challenging moral problem of the twenty-first century will be the relationship between the individual moral agent and the practices and institutions in which the moral agent is embedded. In this paper, we continue the efforts that one of us, Joan Liaschenko, first called for in 1993, that of using feminist ethics as a lens for viewing the relationship between individual nurses as moral agents and the highly complex institutions in which they do the work of nursing. Feminist ethics, with its emphasis on the inextricable relationship between ethics and politics, provides a useful lens to understand the work of nurses in context.

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.

Problems with the electronic health record.

One of the most significant changes in modern healthcare delivery has been the evolution of the paper record to the electronic health record (EHR). In this paper we argue that the primary change has been a shift in the focus of documentation from monitoring individual patient progress to recording data pertinent to Institutional Priorities (IPs). The specific IPs to which we refer include: finance/reimbursement; risk management/legal considerations; quality improvement/safety initiatives; meeting regulatory and accreditation standards; and patient care delivery/evidence based practice.

Constructing the story: How nurses work with families regarding withdrawal of aggressive treatment in ICU – A narrative study.

Background: Specific communication practices used by experienced intensive care nurses who are comfortable working with dying patients and their families in ICU to reach consensus on withdrawal of aggressive treatment and shift to palliative care are lacking in the literature. However, there are seven international qualitative studies relevant to this research. Important themes related to communication were composed of four elements: general communication and relationship building, recognizing the need to transition to palliative care, facilitating palliative care, and providing dignified care through to death.

The fetus, the "potential child," and the ethical obligations of obstetricians.

The right of pregnant women to refuse obstetric interventions is an established tenet of obstetric ethics. However, that does not mean that fetal considerations are inconsequential. Although respect for negative autonomy is largely a settled issue, what is less clear is the degree to which a pregnant woman's affirmative autonomy (the right to demand) should be controlling.

Moral distress reexamined: a feminist interpretation of nurses' identities, relationships, and responsibilites.

Moral distress has been written about extensively in nursing and other fields. Often, however, it has not been used with much theoretical depth. This paper focuses on theorizing moral distress using feminist ethics, particularly the work of Margaret Urban Walker and Hilde Lindemann.

Social justice in pandemic preparedness.

Pandemic influenza planning in the United States violates the demands of social justice in 2 fundamental respects: it embraces the neutrality of procedural justice at the expense of more substantive concern with health disparities, thus perpetuating a predictable and preventable social injustice, and it fails to move beyond lament to practical planning for alleviating barriers to accessing care. A pragmatic social justice approach, addressing both health disparities and access barriers, should inform pandemic preparedness. Achieving social justice goals in pandemic response is challenging, but strategies are available to overcome the obstacles.

To lift or not to lift: patient-handling practices.

Musculoskeletal injury is common among nurses as a result of lifting and handling patients. In response to musculoskeletal injuries, safe patient-handling programs are being instituted to decrease the risk of injuries and resulting impaired function. This study was designed to identify patient-handling practices in clinical practice.

How clinical trials really work rethinking research ethics.

Despite prevalent concerns about the ethical conduct of clinical trials, little is known about the day-to-day work of trials and the ethical challenges arising in them. This paper reports on a study designed to fill this gap and demonstrates a need to refine the oversight system for trials to reflect an understanding of this day-to-day work. It also illuminates ethical challenges that cannot be addressed by the oversight system and so necessitate a rethinking of the ethics of clinical trials.

Institutional geographies in dying: nurses' actions and observations on dying spaces inside and outside intensive care units.

This paper articulates the geographies associated with intensive care nursing work with dying patients and their families. Six focus groups were conducted with 27 registered critical care nurses who practice in hospitals in a mid-western city in the United States. The analysis is structured by three emerging themes (i) the importance of a 'good' and 'sacred' place, (ii) the body as mapped by medical specialties, and (iii) problems with procedurally driven suspension of 'do not resuscitate' orders beyond intensive care units (ICUs).

Respect in forensic psychiatric nurse-patient relationships: a practical compromise.

The context of forensic psychiatric nursing is distinct from other psychiatric settings as, it involves placement of patients in secure environments with restrictions determined by the courts. Previous literature has identified that nurses morally struggle with respecting patients who have committed heinous offences, which can lead to the patient being depersonalized and dehumanized. Although respect is fundamental to ethical nursing practice, it has not been adequately explored conceptually or empirically.

The "big picture": communicating with families about end-of-life care in intensive care unit.

This article presents the findings of a qualitative study investigating how critical care nurses include families in end-of-life care. The major theme, "Supporting the Families' Journey Through the Dying Process," illustrates how critical care nurses organize information to construct the "big picture" of the patients' deteriorating status and artfully communicate this to families.

In the margins of the mind: development of a projective research methodology for the study of nursing practice.

This article presents an original research method derived from the Thematic Apperception Test used in clinical psychology to understand human motivation and action. The research method is derived from the theory of projection, which states that humans will perceive stimuli in terms of their own expectations and motives and will credit others with their own attitudes, beliefs, traits, and dispositions. Projective techniques are one of a handful of methods that provide access to this type of knowledge since it resides below the level of consciousness.

Understanding collaboration between nurses and physicians as knowledge at work.

Background: Collaboration between nurses and physicians is linked to positive outcomes for patients, especially in the intensive care unit. However, effective collaboration poses challenges because of traditional barriers such as sex and class differences, hierarchical organizational structures in health-care, and physicians' belief that they are the final arbiter of clinical decisions.

Objective: To further analyze the results of an investigation on how intensive care unit culture, expressed through everyday practices, affected the care of patients who became confused.

In the mind of the beholder: hypothesized effect of intrapartum nurses' cognitive frames of childbirth cesarean section rates.

In this article, the authors present the central finding of a study aimed at identifying possible relationships between the ways in which labor and delivery (L&D) nurses cognitively frame childbirth and cesarean section (CS) rates. They recruited 51 L&D nurses employed at two hospitals in a Midwestern city in the United States to participate in the study, in which they used a projective method to explore nurses' views about the meaning of childbirth and their possible relationship to CS. The authors selected a projective method for this research to identify the preconscious beliefs that inform clinical action.