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Omar Hasan Kasule Sr1 and Lin Naing1
1Institute of Medicine, Universiti Brunei Darussalam
Abstract (385 words)
The paper reports results of an assessment of knowledge and practice of medical ethics among nurses in a public hospital before and after an intervention which consisted of a training workshop on medical ethics and provision of reading material on ethics. The results of the study were to be used to formulate policies on ethical training for healthcare workers. The questionnaire used had been employed previously in research on ethics [1]. Respondents were presented with case scenarios. They were asked to choose the best among 3-4 approaches to resolving the ethical problem(s) in each scenario. The questionnaire was administered a few hours before the workshop on ethics. The participants were asked to complete the same questionnaire within 1 month of the ethics workshop. To make sure that responders gave honest answers, no personal identifiers were included on the questionnaires. Data was key-punched and analyzed using the SPSS program. Data analysis focused on estimating the proportion of participants who changed responses to the scenarios after the ethics training workshop. There was no interest in studying whether the responses were correct or not. Pre- and post intervention responses were compared and coded as ‘change’ or ‘no change’. The frequencies, proportions (percentages), and binomial 95% confidence intervals were calculated using Stata/IC 10.0. The degree of change for each question was graded as ‘little’ for changes in <10% of respondents, ‘some’ for 10 to <30%, ‘moderate’ for 30 to <50% and ‘great’ for 50% and above. Eighty two out of the 83 nurses who attended the workshop returned both the pre- and post-intervention questionnaires. The percentage of respondents who changed their responses to questions after the intervention ranged from 15.5% to 56.5%. On average of 37.4% and 29.2% of respondents changed in Islamic questions and general questions respectively. The most changed five questions are Islamic questions in the aspects of ‘animal research’ (56.5%), ‘life support’ (43.2%), ‘euthanasia’ (42.2%), ‘halal medicine’ (40%), and ‘needles to addicts’ (39.1%). The conclusion from the study is that there were considerable changes in response to questions after the intervention and greater changes were observed in the Islamic questions than in the general questions. It is recommended, after further studies to corroborate this finding, that teaching of medical ethics should consider the religious medium because it seems to have a bigger impact on the trainees.
Key words: nurses ethics training
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INTRODUCTION
• Cross sectional questionnaire
• pre and post
• Intervention: workshop on ethics
• 83 respondents
• Interest in change not validity
• % Change for each question
METHODS
RESULTS
• Overall change 15.5 – 56.5%
• Islamic questions 37.4%
• General questions 29.2%
MOST CHANGED QUESTIONS
• animal research 56.5%
• life support 43.2%
• euthanasia 42.2%
• halal medicine 40%
• needles to addicts 39.1%.
CONCLUSIONS
• Considerable changes after the intervention
• Islamic questions > general questions
• Recommend teaching medical ethics from a religious medium
1. Naznin Muhammad et al. The impact of the teaching of medical ethics in the medical and allied health sciences curriculum in International Islamic University Malaysia. Paper being submitted to the International Medical Journal (personal communication)
Brzostek T, Dekkers W, Zalewski Z, Januszewska A, Górkiewicz M. Perception of palliative care and euthanasia among recently graduated and experienced nurses. Nurs Ethics. 2008 Nov;15(6):761-76.
Palliative care and euthanasia has become the subject of ethical and political debate in Poland. However, the voice of nurses is rarely heard. The aim of this study is to explore the perception of palliative care and euthanasia among recent university bachelor degree graduates and experienced nurses in Poland. Specific objectives include: self-assessment of the understanding of these terms, recognition of clinical cases, potential acceptability of euthanasia, and an evaluation of attitudes towards palliative care and euthanasia. This is an exploratory study. A convenience sample of 206 recent graduates and 252 experienced nurse practitioners were interviewed. A structured questionnaire was used for collecting and interpreting data. Subjective perception of the terms; palliative care' and; euthanasia’ was high and consistent with the recognition of clinical cases. The majority of the nurses excluded euthanasia from palliative care. They recognized personal philosophy of life as the most influential factor affecting attitudes towards euthanasia. The importance of the law was valued more highly by the experienced nurses.
McMillen RE. End of life decisions: nurses perceptions, feelings and experiences. Intensive Crit Care Nurs. 2008 Aug;24(4):251-9. Epub 2007 Dec 26.
Decisions to withdraw treatment are made on a regular basis in intensive care units. While nurses play a central role in patient care, previous studies have found that they are not always involved in withdrawal decisions. AIM: To explore the experiences of ICU nurses caring for patients who have had their treatment withdrawn and to answer two research questions: what role do nurses play and how does this affect them? METHOD: Constructivist grounded theory was used to explore the experiences and feelings of ICU nurses. A purposive sample of eight ICU nurses participated and semi-structured interviews were used to collect data. Framework analysis was used to facilitate systematic analysis. RESULTS: The analysis revealed two major themes (1) the nurse's role: experience counts, not really a nurse's decision, planting the seed, supporting the family and being a patient advocate and (2) perceptions of the withdrawal of treatment: getting the timing right and emotional labour. CONCLUSIONS: Nurses make an important contribution to end of life decisions and care. Guidelines recommend they have input into withdrawal decisions, therefore it is imperative that nurses are supported in this role and their responsibilities to continue to provide care during withdrawal.
Eliasson M, Kainz G, von Post I. Uncaring midwives. Nurs Ethics. 2008 Jul;15(4):500-11.
The aim of this study was to understand how mothers experienced midwives' uncaring behaviour and actions during birth. Sixty-seven first-time mothers took part in the study, in which data were collected through interview. The interview text was analysed using hermeneutic text analysis. Nearly half of the mothers interviewed (n = 32) said that midwives did not care for them. The findings show that midwives' behaviour was humiliating when they ignored mothers and held them in contempt. The mothers felt further humiliated when the midwives did not believe them, treated their bodies in a careless manner and tended to put blame on them. Through their behaviour and actions, some midwives have shown that they no longer have a caring attitude as an element of their professional practice and that they have ignored ethics by offending mothers' sense of dignity.
Engebretson J, Mahoney J, Carlson ED. Cultural competence in the era of evidence-based practice. J Prof Nurs. 2008 May-Jun;24(3):172-8.
Cultural competence has become an important concern for contemporary health care delivery, with ethical and legal implications. Numerous educational approaches have been developed to orient clinicians, and standards and position statements promoting cultural competence have been published by both the American Medical Association and the American Nurses Association. Although a number of health care regulatory agencies have developed standards or recommendations, clinical application to patient care has been challenging. These challenges include the abstract nature of the concept, essentializing culture to race or ethnicity, and the attempts to associate culture with health disparities. To make cultural competence relevant to clinical practice, we linked a cultural competency continuum that identifies the levels of cultural competency (cultural destructiveness, cultural incapacity, cultural blindness, cultural precompetence, and cultural proficiency) to well-established values in health care. This situates cultural competence and proficiency in alignment with patient-centered care. A model integrating the cultural competency continuum with the components of evidence-based care (i.e., best research practice, clinical expertise, and patient's values and circumstances) is presented.
Civaner M, Sarikaya O, Alici SU, Bozkurt G.Exposing nursing students to the marketing methods of pharmaceutical companies. Nurs Ethics. 2008 May;15(3):396-410.
There is a strong association between reliance on the promotional activities of pharmaceutical companies and a generally less appropriate use of prescription drugs. Pharmaceutical companies direct some of their promotion towards health workers who do not have the authority to prescribe medicines, such as nurses in certain countries. The aim of this study was to determine the impact that exposure to the marketing methods of pharmaceutical companies has on judgments made by nursing students about health worker-pharmaceutical company relationships. A cross-sectional survey was carried out with 442 nursing students in Istanbul, Turkey. The exposure of students to the marketing methods of pharmaceutical companies, whether it be indirectly through observation or directly by first-hand experience, increases the probability that students will adopt rationales that underlie affirmative judgments of health worker-pharmaceutical company relationships. Based on the pervasiveness and ability of drug promotion to influence the perceptions of students, it is imperative that attempts be made to reduce its negative impact.
Maier-Lorentz MM. Transcultural nursing: its importance in nursing practice. J Cult Divers. 2008 Spring;15(1):37-43.
Transcultural nursing is an essential aspect of healthcare today. The ever-increasing multicultural population in the United States poses a significant challenge to nurses providing individualized and holistic care to their patients. This requires nurses to recognize and appreciate cultural differences in healthcare values, beliefs, and customs. Nurses must acquire the necessary knowledge and skills in cultural competency. Culturally competent nursing care helps ensure patient satisfaction and positive outcomes. This article discusses changes that are important to transcultural nursing. It identifies factors that define transcultural nursing and analyzes methods to promote culturally competent nursing care. The need for transcultural nursing will continue to be an important aspect in healthcare. Additional nursing research is needed to promote transcultural nursing.
Catlin A, Armigo C, Volat D, Vale E, Hadley MA, Gong W, Bassir R, Anderson K. Conscientious objection: a potential neonatal nursing response to care orders that cause suffering at the end of life? Study of a concept. Neonatal Netw. 2008 Mar-Apr;27(2):101-8.
This article is an exploratory effort meant to solicit and provoke dialog. Conscientious objection is proposed as a potential response to the moral distress experienced by neonatal nurses. The most commonly reported cause of distress for all nurses is following orders to support patients at the end of their lives with advanced technology when palliative or comfort care would be more humane. Nurses report that they feel they are harming patients or causing suffering when they could be comforting instead. We examined the literature on moral distress, futility, and the concept of conscientious objection from the perspective of the nurse's potential response to performing advanced technologic interventions for the dying patient. We created a small pilot study to engage in clinical verification of the use of our concept of conscientious objection. Data from 66 neonatal intensive care and pediatric intensive care unit nurses who responded in a one-month period are reported here. Interest in conscientious objection to care that causes harm or suffering was very high. This article reports the analysis of conscientious objection use in neonatal care.
van Bruchem-van de Scheur A, van der Arend A, van Wijmen F, Abu-Saad HH, ter Meulen R. Dutch nurses' attitudes towards euthanasia and physician-assisted suicide. Nurs Ethics. 2008 Mar;15(2):186-98.
This article presents the attitudes of nurses towards three issues concerning their role in euthanasia and physician-assisted suicide. A questionnaire survey was conducted with 1509 nurses who were employed in hospitals, home care organizations and nursing homes. The study was conducted in the Netherlands between January 2001 and August 2004. The results show that less than half (45%)of nurses would be willing to serve on committees reviewing cases of euthanasia and physician-assisted suicide. More than half of the nurses (58.2%) found it too far-reaching to oblige physicians to consult a nurse in the decision-making process. The majority of the nurses stated that preparing euthanatics (62.9%) and inserting an infusion needle to administer the euthanatics (54.1%) should not be accepted as nursing tasks. The findings are discussed in the context of common practices and policies in the Netherlands, and a recommendation is made not to include these three issues in new regulations on the role of nurses in euthanasia
and physician-assisted suicide.
Rabetoy CP, Bair BC. Nephrology nurses' perspectives on difficult ethical issues and practice guideline for shared decision making. Nephrol Nurs J. 2007 Nov-Dec;34(6):599-606, 629; quiz 607.
Nephrologists and nephrology nurses have struggled with the technological, financial, and ethical concerns surrounding the life sustaining treatment of hemodialysis for as long as this treatment as been available. One of the overriding issues for the nephrology community has been appropriate utilization of this technology and the appropriate restraint for prescribing dialysis. Since the inception of dialysis, there has been discussion of guidelines for deciding who should receive and who should not receive this therapy. In 2000, a clinical guideline was developed to assist in directing the care of patients. The knowledge and acceptance of this guideline by nephrologists has been researched in the past. However, there is no data of knowledge and acceptance of the guideline by nephrology clinical nurses or nephrology nurse practitioners. A survey was conducted to begin to ascertain this information in order to better understand the perspectives of nephrology nurses.
Tang PF, Johansson C, Wadensten B, Wenneberg S, Ahlström G. Chinese nurses' ethical concerns in a neurological ward. Nurs Ethics. 2007 Nov;14(6):810-24.
Our aim was to describe Chinese nurses' experiences of workplace distress and ethical dilemmas on a neurological ward. Qualitative interviews were performed with 20 nurses. On using latent content analysis, themes emerged in four content areas: ethical dilemmas, workplace distress, quality of nursing and managing distress. The ethical dilemmas were: (1) conflicting views on optimal treatment and nursing; (2) treatment choice meeting with financial constraints; and (3) misalignment of nursing responsibilities, competence and available resources. The patients' relatives lacked respect for the nurses' skills. Other dilemmas could be traced to the transition from a planned to a market economy, resulting in an excessive workload and treatment withdrawal for financial reasons. Lack of resources was perceived as an obstacle to proper patient care in addition to hospital organization, decreasing the quality of nursing, and increasing moral and workplace distress. The nurses managed mainly by striving for competence, which gave them hope for the future.
Vanlaere L, Gastmans C. Ethics in nursing education: learning to reflect on care practices. Nurs Ethics. 2007 Nov;14(6):758-66.
Providing good care requires nurses to reflect critically on their nursing practices. Ethics education must provide nurses with tools to accomplish such critical reflection. It must also create a pedagogical context in which a caring attitude can be taught and cultivated. To achieve this twofold goal, we argue that the principles of a right-action approach, within which nurses conform to a number of minimum principles, must be integrated into a virtue ethics approach that cultivates a caring attitude. Ethics education that incorporates both the ;critical companionship' method and the use of codes of ethics contributes positively to cultivating critical reflection by nurses.
Holmström I, Höglund AT. The faceless encounter: ethical dilemmas in telephone nursing. J Clin Nurs. 2007 Oct;16(10):1865-71.
AIM: This paper aims to present the findings of a study designed to describe ethical dilemmas, in the form of conflicting values, norms and interests, which telenurses experience in their work. BACKGROUND: Telephone nursing is an expanding part of health care. Telephone nurses in Sweden assess care needs, provide advice, support and information, and recommend and coordinate healthcare resources. Lately, ethical demands on healthcare professionals in general have increased. The reasons include new biomedical competence, an ageing population and constrained resources which have made priority setting a primary concern for doctors and nurses. When ethical problems arise, colleagues need open dialogue. Despite this, nurses lack such a dialogue. METHOD: A purposeful sample of 12 female telenurses in Sweden was interviewed twice during 2004 and 2005. The transcribed interviews were analysed thematically. RESULTS: Five themes were found: talking through a third party; discussing personal and sensitive problems over the phone; insufficient resources and the organization of health care; balancing callers' information needs with professional responsibility; and differences in judging the caller's credibility. CONCLUSION: The present study has identified five different themes in which Swedish telenurses experience ethical dilemmas in their work. This shows how ethical dilemmas in various forms are present in telenursing. Questions of autonomy, integrity and prioritizing are particularly highlighted by the participating nurses. Telenurses in Sweden also experience new ethical demands due to a multicultural society. Although several of the identified dilemmas also occur in other areas of nursing we argue that these situations are particularly challenging in elenursing. RELEVANCE TO CLINICAL PRACTICE: The work organization should provide opportunities for ethical competence-building, where ethical dilemmas in telenursing are highlighted and discussed. Such a strategy might lead to decreased moral uncertainty and distress among telenurses, with positive consequences for callers.
Doolen J, York NL. Cultural differences with end-of-life care in the critical care unit. Dimens Crit Care Nurs. 2007 Sep-Oct;26(5):194-8.
Critical care nurses are providing healthcare for an increasingly multicultural population. This ever-increasing diversity in cultures and subcultures presents a challenge to nurses who want to provide culturally competent care. It is common for patients and families to face difficult decisions about end-of-life care in critical care units, and minority cultures do not always believe in the Westerner's core values of patient autonomy and self-determination. Knowledge of these cultural differences is fundamental if critical care nurses wish to provide appropriate and culturally competent information regarding end-of-life decisions.
Kumaş G, Oztunç G, Nazan Alparslan Z. Intensive care unit nurses' opinions about euthanasia. Nurs Ethics. 2007 Sep;14(5):637-50.
This study was conducted to gain opinions about euthanasia from nurses who work in intensive care units. The research was planned as a descriptive study and conducted with 186 nurses who worked in intensive care units in a university hospital, a public hospital, and a private not-for-profit hospital in Adana, Turkey, and who agreed to complete a questionnaire. Euthanasia is not legal in Turkey. One third (33.9%) of the nurses supported the legalization of euthanasia, whereas 39.8% did not. In some specific circumstances, 44.1% of the nurses thought that euthanasia was being practiced in our country. The most significant finding was that these Turkish intensive care unit nurses did not overwhelmingly support the legalization of euthanasia. Those who did support it were inclined to agree with passive rather than active euthanasia (P = 0.011).
Ellilä H, Välimäki M, Warne T, Sourander A. Ideology of nursing care in child psychiatric inpatient treatment. Nurs Ethics. 2007 Sep;14(5):583-96.
Research on nursing ideology and the ethics of child and adolescent psychiatric nursing care is limited. The aim of this study was to describe and explore the ideological approaches guiding psychiatric nursing in child and adolescent psychiatric inpatient wards in Finland, and discuss the ethical, theoretical and practical concerns related to nursing ideologies. Data were collected by means of a national questionnaire survey, which included one open-ended question seeking managers' opinions on the nursing ideology used in their area of practice. Questionnaires were sent to all child and adolescent psychiatric inpatient wards (n = 69) in Finland; 61 ward managers responded. Data were analysed by qualitative and quantitative content analysis. Six categories -- family centred care, individual care, milieu centred care, integrated care, educational care and psychodynamic care -- were formed to specify ideological approaches used in inpatient nursing. The majority of the wards were guided by two or more approaches. Nursing models, theories and codes of ethics were almost totally ignored in the ward managers' ideological descriptions.
Ashmore R, Carver N, Banks D. Mental health nursing students' relationships with the pharmaceutical industry. Nurse Educ Today. 2007 Aug;27(6):551-60. Epub 2006 Nov 20.
INTRODUCTION: The medical profession's relationship with the pharmaceutical industry (PI) has come under increased scrutiny in recent years, however little is known on the subject in mental health nursing. AIMS: The study sought to investigate: (1) the frequency of contact between mental health nursing students and PI employees; (2) students' attitudes and beliefs about their relationship with the PI; (3) the range of 'gifts', promotional items and hospitality accepted or seen in clinical environments by students in a one year period; and (4) students’ attitudes to 'gifts', promotional items and hospitality offered by the industry. METHOD: Employing a survey design, a 35-item questionnaire was distributed to 472 students at two universities in the UK. Data were analysed from 347 respondents by means of descriptive statistics and simple content analysis. RESULTS: The findings suggest that students have significant contact with the industry through one-to-one meetings with pharmaceutical representatives (PRs) and by attending events giving information on specific drugs or general mental health issues. Students also identified a number of benefits (e.g. receiving "up-to-date" information on new drugs) and problems (e.g. the potential influence exerted on practitioners to use their drugs) arising out of this contact. Most students (79.8%) had accepted some form of 'gift' from the industry but few (11.5%) believed it was unacceptable to do so. The presence of promotional items in the clinical environment was seen as advertising (84.4%) but few students (19.3%) believed clinical environment should be free of these items. Over half (57.1%) of the students believed that PRs did not always give unbiased information but thought that they and mental health nurses in general would be able to detect any bias. CONCLUSIONS: In parallel with medicine, the study has shown that the pharmaceutical industry has at least the potential to influence mental health nursing students. Within medicine this realisation has triggered a vigorous debate on how medical schools should respond to the promotional activities of the PI. We suggest this study goes some way to demonstrating there is a need for these issues to be debated in the education of mental health nurses.
Kalb KA, O'Conner-Von S. Ethics education in advanced practice nursing: respect for human dignity. Nurs Educ Perspect. 2007 Jul-Aug;28(4):196-202.
Ethics education is an essential component of academic programs that prepare nurses for advanced practice; the concept of respect for human dignity is integral to this education. Sixty-three graduate students enrolled in their first course of a nurse practitioner program completed a researcher-developed Ethics Questionnaire that was designed to elicit their baseline ethics-related knowledge, including their understanding of the concept "respect for human dignity". Qualitative analysis of data yielded findings that validate the importance of using the American Nurses Association Code of Ethics for Nurses with Interpretive Statements as an essential foundation for ethics content and as a framework for understanding the meaning of human dignity in advanced practice nursing. Assessment and learning strategies are recommended.