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. (shrink)

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. (shrink)

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. (shrink)

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. Using Margaret Urban Walker's and Hilde Lindemann's concepts of identity, relationships, values, and moral agency, we argue that health care institutions can be moral communities and profoundly affect the work and identity and, therefore, the moral agency of all who work within those structures, including nurses. Nurses are not only shaped by these organizations but also have the power to shape them. Because moral agency is intimately connected to one's identity, moral identity work is essential for nurses to exercise their moral agency and to foster moral community in health care organizations. We first provide a brief history of nursing's morally problematic relationship with institutions and examine the impact institutional master narratives and corporatism exert today on nurses’ moral identities and agency. We close by emphasizing the significance of ongoing dialogue in creating and sustaining moral communities, repairing moral identities, and strengthening moral agency. (shrink)

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 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 relationships as central to beginning the process, social and political influences on decision making, complex roles and responsibilities of family members and healthcare providers, a unique experience of death, and 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. (shrink)

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. (shrink)

-/- Background: Nurses who provide aggressive care often experience the ethical challenge of needing to preserve the hope of seriously ill patients and their families without providing false hope. -/- Research objectives: The purpose of this inquiry was to explore nurses’ moral competence related to fostering hope in patients and their families within the context of aggressive technological care. A secondary purpose was to understand how this competence is shaped by the social–moral space of nurses’ work in order to capture (...) how competencies may reflect an adaptation to a less than ideal work environment. -/- Research design: A critical qualitative approach was used. -/- Participants: Fifteen graduate nursing students from various practice areas participated. -/- Ethical considerations: After receiving ethics approval from the university, signed informed consent was obtained from participants before they were interviewed. -/- Findings: One overarching theme ‘Mediating the tension between providing false hope and destroying hope within biomedicine’ along with three subthemes, including ‘Reimagining hopeful possibilities’, ‘Exercising caution within the social–moral space of nursing’ and ‘Maintaining nurses’ own hope’, was identified, which represents specific aspects of this moral competency. -/- Discussion: This competency represents a complex, nuanced and multi-layered set of skills in which nurses must be well attuned to the needs and emotions of their patients and families, have the foresight to imagine possible future hopes, be able to acknowledge death, have advanced interpersonal skills, maintain their own hope and ideally have the capacity to challenge those around them when the provision of aggressive care is a form of providing false hope. -/- Conclusion: The articulation of moral competencies may support the development of nursing ethics curricula to prepare future nurses in a way that is sensitive to the characteristics of actual practice settings. (shrink)

The growth and sustainability of the nursing profession depends on the ability to recruit and retain the upcoming generation of professionals. Understanding the career choice experiences and professional expectations of Millennial nurses (born 1980 or after) is a critical component of recruitment and retention strategies. This study utilized Polkinghorne's interpretive, narrative approach to understand how Millennial nurses explain, account for and make sense of their choice of nursing as a career. The positioning of nursing as a virtuous choice was both (...) temporally and contextually influenced. The decision to enter the profession was initially emplotted around a traditional understanding of nursing as a virtuous profession: altruistic, noble, caring and compassionate. The centricity of virtues depicts one‐dimensional understanding of the nursing profession that alone could prove dissatisfying to a generation of professionals who have many career choices available to them. The narratives reveal how participants' perceptions and expectations remain influenced by a stereotypical understanding of nursing, an image that remains prevalent in society and which holds implications for the future recruitment, socialization and retention strategies for upcoming and future generations of nurses. (shrink)

The history of nursing in the home: revealing the significance of place in the expression of moral agency The relationship between place and moral agency in home care nursing is explored in this paper. The notion of place is argued to have relevance to moral agency beyond moral context. This argument is theoretically located in feminist ethics and human geography and is supported through an examination of historical documents (1900–33) that describe the experiences and insights of American home care/private duty (...) nurses or that are related to nursing ethics. Specifically, the role of place in inhibiting and enhancing care, justice, good relationships, and power in the practice of private duty nurses is explored. Several implications for current nursing ethics come out of this analysis. (i) The moral agency of nurses is highly nuanced. It is not only structured by nurses’ relationships to patients and health professionals, i.e. moral context, it is also structured by the place of nursing care. (ii) Place has the potential to limit and enhance the power of nurses. (iii) Some aspects of nursing's conception of the good, such as what constitutes a good nurse–patient relationship, are historically and geographically relative. (shrink)

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. (shrink)

Medical futility is often defined as providing inappropriate treatments that will not improve disease prognosis, alleviate physiological symptoms, or prolong survival. This understanding of medical futility is problematic because it rests on the final outcomes of procedures that are narrow and medically defined. In this article, Walker's `expressivecollaborative' model of morality is used to examine how certain critical care interventions that are considered futile actually have broader social functions surrounding death and dying. By examining cardiopulmonary resuscitation and life-sustaining intensive care (...) measures as moral practices, we show how so-called futile interventions offer ritualistic benefit to patients, families, and health care providers, helping to facilitate the process of dying. This work offers a new perspective on the ethical debate concerning medical futility and provides a means to explore how the social value of treatments may be as important in determining futility as medical scientific criteria. (shrink)

Explorations of a trust approach for nursing ethicsTrust has long been acknowledged as central to nurse–patient relationships. It, however, has not been fully explored nor‐matively. That is, trust must be examined from a perspective that encompasses not only reliability and competence, but also good will within nursing relationships. In this paper, we explore how a trust approach, based on Annette Baier’s work on trust in feminist ethics, could help inform future developments in nursing ethics. We discuss the limitations of other (...) approaches such as those based on contracts, paternalism, and care. By drawing out central features of Baier’s theory, we demonstrate how it can help overcome the problems of these previous models. In doing so, we emphasise the importance of combining the ethics of care and justice, acknowledging vulnerability and the potential for evil in nursing relationships, and politically situating the ethical concerns of nursing. (shrink)

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’. (shrink)

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. (shrink)

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. (shrink)

Sister (Sr.) Marie Simone Roach, of the Sisters of St. Martha of Antigonish, Nova Scotia, died at the Motherhouse on 2 July 2016 at the age of 93, leaving behind a rich legacy of theoretical and practical work in the areas of care, caring and nursing ethics. She was a humble soul whose deep and scholarly thinking thrust her onto the global nursing stage where she will forever be tied to a central concept in nursing, caring, through her Six Cs (...) of Caring model. In Canada, she was the lead architect of the Canadian Nurses Association's first code of ethics, and her influence on revisions to it is still profound more than 35 years later. In this paper, four global scholars in nursing and ethics are invited to reflect on Sr. Simone's contribution to nursing and health‐care, and we link her work to nursing and health‐care going forward. (shrink)

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. Incorporating empirical findings, we argue that moral distress is the response to constraints experienced by nurses to their moral identities, responsibilities, and relationships. We recommend that health professionals get assistance in accounting for and communicating their values and (...) responsibilities in situations of moral distress. We also discuss the importance of nurses creating “counterstories” of their work as knowledgeable and trustworthy professionals to repair their damaged moral identities, and, finally, we recommend that efforts toward shifting the goal of health care away from the prolongation of life at all costs to the relief of suffering to diminish the moral distress that is a common response to aggressive care at end-of-life. (shrink)

BackgroundWith 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. (...) MethodA 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.ResultsThemes 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.DiscussionTo 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. (shrink)

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. (shrink)