Reclaiming ‘Big Nurse’: a feminist critique of Ken Kesey's portrayal of Nurse Ratched in One Flew Over the Cuckoo's Nest Nurse Ratched or ‘Big Nurse’ in Ken Kesey's counter‐culture novel One Flew Over the Cuckoo's Nest is one of popular culture's most arresting and memorable images of the nurse. She is, however, deemed to be remarkable primarily for her malice and authoritarianism. This paper argues that such a purely realist reading fails to fully appreciate the (...) significance of the character of Nurse Ratched. A feminist critique of the novel contends that die importance of ‘Big Nurse’ is less related to how realistic/unrealistic or good/bad she is as a nurse. Nurse Ratched is important because she exemplifies all diat traditional masculinity abhors in women, and particularly in strong women in positions of power and influence. This paper explores the stereotype of ‘Big Nurse’ and argues that Kesey's vision of her ultimate ‘conquest’ is not a progressive allegory of ‘individual freedom’, but a reactionary misogyny which would deny women any function other than that of sexual trophy. (shrink)

Background: Discrimination and injustice are big obstacles in nurses’ way to socialization and are among the major clinical challenges faced by nurses. Workplace discrimination is associated with such negative consequences as stress, fatigue, demoralization, loss of professional commitment, tension and conflicts at work, and resignation. A review of literature shows that not much research has been dedicated to workplace discrimination in nursing. Objective: This study aims to investigate nurses’ perception of workplace discrimination. Method: This cross-sectional study was conducted in the (...) hospitals affiliated with a university of medical sciences in the largest city in the south of Iran in 2019. The participants consisted of 597 nurses who were selected through stratified random sampling. Data were collected using a researcher-made workplace discrimination questionnaire and analyzed in SPSS v. 21. Findings: The mean of the nurses’ workplace discrimination scores was found to be 102.57 ± 14.5, which is considered as moderate. The nurses’ mean scores for the dimensions of vertical and horizontal discrimination, consequences of discrimination, and unfair promotion were moderate. As for the two other dimensions of workplace discrimination, namely, gender discrimination and cultural-organizational discrimination, the participants’ mean scores were low. There was a significant relationship between the nurses’ workplace discrimination mean score on the one hand and their employment status and work experience on the other. However, the nurses’ workplace discrimination mean score was not found to correlate with their level of education, marital status, and gender. Ethical consideration: This study has been approved by the ethics committee of the university. All the participants had signed the written informed consent form before participation. Conclusion: Hospital managers should take measures to reduce discrimination and establish organizational justice to raise nurses’ morale and improve the quality of their performance as caregivers. (shrink)

In the crucible of the pandemic, it has never before been clearer that, to ensure the relevance and even the survival of the discipline, nursing must cultivate a radical imagination. In the paper that follows, I trace the imperative for conjuring a radical imagination for nursing. In this fever dream for nursing futures, built on speculative visions of what could be, I draw on anarchist, abolitionist, posthuman, Black feminist, new materialist and other big ideas to plant seeds of generative insurrection (...) and creative resistance. In thinking through a radical imagination, I unpack the significance of reparatory history for nursing, a discipline founded on normative whiteness. From there, I consider what it would take to shift the capitalist frame of healthcare to one of mutual aid, which requires the deep work of abolition. With a radical imagination that breaks down the enclosures that contain us through reparatory history, mutual aid and abolition, kinship becomes urgently possible. (shrink)

The nursing gaze, that is the specific ways of observing the patient in nursing practice, has been the object of ethical debates for decades. It has been argued that the specific feature of observing patients in nursing is the stereoscopic vision that allows nurses to see the patient at the same time as a subject and a body. However, with the increased use of technology in nursing and the focus on quantifiable biomedical data, some commentators see a shift from the (...) view of the patient as subject to the patient as body, which results in a de‐humanisation and objectification of patients. The new digital technologies in patient monitoring and surveillance add a further dimension to this topic. It is yet unclear how digital technologies affect the nursing gaze, and with it, nursing practice. Furthermore, the ethical implications of the digitally enhanced nursing gaze have yet to be analysed. It is the purpose of this study to make a first step in this direction. By focusing on digitally enhanced monitoring technologies in long‐term care, these technologies are interpreted as liquid surveillance, an approach introduced by Zygmunt Bauman. The Baumanian concept of adiaphorisation, that is the detachment of social action from moral evaluation, is used as normative framework of the analysis. The analysis shows that the tendency to remove surveillance practices from moral evaluation by framing them as enablers of an active, healthy life and as tools for caring for the vulnerable, the stereoscopic vision of the nursing gaze is undermined. (shrink)

To enhance patient care in the inevitable conditions of complexity that exist in contemporary healthcare, collaboration among healthcare professions is critical. While each profession necessarily has its own primary focus and perspective on the nature of human healthcare needs, these alone are insufficient for meeting the complex needs of patients (and potential patients). Persons are inevitably contextual entities, inseparable from their environments, and are subject to institutional and social barriers that can detract from good care or from accessing healthcare. These (...) are some of the reasons behind current movements to develop competency frameworks that can enhance cross‐disciplinary communication and collaboration. No single profession can claim the big picture. Effective teamwork is essential and requires members of diverse professions to understand the nature of each other's knowledge, skills, roles, perspectives, and perceived responsibilities so that they are optimally utilized on behalf of patients and their families. Interdisciplinary approaches to care permit different aspects of a person's needs to be addressed seamlessly and facilitate the removal of obstacles by engaging the range of resources exemplified by the different professions. Additionally, collaborative efforts are needed to influence policy changes on behalf of individual and social good and to address root causes of poor health especially as these impact society's most vulnerable. Here, we explore both the benefits and the risks of an uncritical acceptance of competency frameworks as a way to enhance interdisciplinary communication. We highlight the importance of anchoring proposed competency domains in the reason for being of a given profession and exemplify one way this has been accomplished for advanced practice nursing. Additionally, we argue that having this mooring, permits integration of the various competencies that both enhances professional moral agency and facilitates interdisciplinary collaboration to further the mutual goals of the healthcare professions on behalf of quality patient care. (shrink)

Background: Providing information to patients is an essential aspect of care. The way in which such information is transmitted is also important and is affected by different variables. The perceptions of dishonest nursing staff have not been sufficiently discussed to date. Aim: The purpose is to explore the reasons for dishonesty in transmitting information to patients. Design and Method: In this qualitative content analysis study, data were collected using semi-structured interviews with Twelve Iranian Critical Care Nurses from January 2020 till (...) August 2020. Data were analyzed according to Graneheim and Lundman approach. Ethical consideration: The research protocol was authorized by the Ethics Committee of the Medical Sciences University of Tehran (Register number: 95-04-99-33485). Results: The findings indicated that dishonesty in giving information to the patients has many reasons. Although lying is not compatible with ethical care, working conditions sometimes forced nurses to hide the truth. Discussion and conclusion: Nurses believed honesty was an integral aspect of professional practice, but situational specifics have an effect on whether the truth is told or withheld. Finally, the nurses noticed a big gap between what they want to tell and what they were doing in practice. (shrink)

Aging has become a serious social problem in China. Traditional informal long-term care is hard to sustain because of the reduction in family size and elders’ children migration to big cities. The institution offering services for the disabled elders has been a tendency. There exists a strange phenomenon: some nursing homes are difficult to enter for most disabled elders, while the other ones must search for elders to maintain operation. Therefore, for the evaluation of nursing homes, two problems should be (...) considered: selecting suitable nursing homes for disabled elders; obtaining the key factors influencing the selection of elders and helping nursing homes improve their services based on the key factors. First, we propose a new DEMATEL method for PLTSs to solve the second problem. Then, we present a novel PROMETHEE method to rank the alternatives and make a sensitivity analysis for criteria. Finally, we illustrate our proposed methods to an evaluation problem in Zhenjiang City by a case study. Based on the case study, we can obtain that our proposed methods are effective and practicable. (shrink)

The aim of this study was to explore neonatal nurses’and mothers of preterm infants’experiences of daily challenges. Interviews took place asking for good, bad and challenging experiences. Data were analysed using qualitative content analysis and findings were clustered in two categories: good and challenging experiences, each containing three themes. The good experiences were: managing with success as a nurse, small things matter for mothers, and a good day anyhow for mothers and nurses. The challenging experiences were: mothering in public, (...) being pulled between responsibilities, and adverse things stick under the nurses’skin. The study shows that small daily clinical matters become big issues and could lead to moral distress, and that nurses integrate ethics of justice and ethics of care while mothers are concerned about health and well-being of their specific infant only. The challenge for nursing to integrate fairness and sensitive care in family-oriented neonatal care is discussed. (shrink)

This population study examined the incremental validity of spirituality in predicting burnout among Maltese professional nurses. Cross-sectional and mixed-method design was conducted. Measures in this self-report questionnaire included the Maslach Burnout Inventory, Faith Maturity Scale, Satisfaction with Life Scale, Big Five Inventory and a demographic section, together with a brief qualitative section. Response rate was 78%. All hypotheses were supported. Maltese nurses suffer from high levels of burnout, in particular from low professional accomplishment, high levels of depersonalization, and moderate to (...) high emotional exhaustion. Qualitative data supported these findings and suggested that the physical and moral environment of nurses was conducive to an increase of burnout. Furthermore, multiple regression analysis indicated that spirituality predicted burnout after controlling for personality and well-being. This study suggests that spirituality may be an important potential source of resilience for nurses who risk burnout in their employment. (shrink)

Derek Nurse looks at variations in the form and function of tense and aspect in Bantu, a branch of Niger-Congo, the world's largest language phylum. Bantu languages are spoken in central, eastern, and southern sub-Saharan Africa south of a line between Nigeria and Somalia. By current estimates there are between 250 and 600 of them, as yet neither adequately classified nor fully described. Professor Nurse's account is based on data from more than 200 Bantu languages and varieties, a (...) representative sample of which is freely available on the publisher's website. He devotes substantial chapters to the analysis and comparison of the different tense and aspect systems found in Bantu. He also examines the verbal categories with which they interact, including negation and focus. Synchronic and diachronic perspectives are interwoven throughout the book. Following a brief history of Bantu over the last five thousand years, the final two chapters look systematically at the history of tense and aspect in Bantu. The first deals with the reconstruction of the earlier forms from which contemporary structures, morphemes, and categories are derived, and the second with the processes of change, including grammaticalization, by means of which older analytical structures and independent lexical items moved as they became incorporated as grammatical inflections and categories. (shrink)

Despite achieving broad acceptance of the moral case for treating animals fairly, the animal rights movement has reached an impasse concerning legal rights for animals. Zoopolis proposes a new approach to addressing this failure: integrating animal interests into human society via political institutions and practices. Zoopolis’s central theory that humans owe animals citizenship rights in a shared human-animal society, but that acceptance of responsibilities by animals also is required, has merit for the advancement of animal rights discourse. But its anthropocentric (...) approach, which itself exerts power over animals, necessitating suppression and policing of animals’ natural behavior, is problematic. (shrink)

The renowned Nobel Prize-winning scientist's elegant and concise explanation of the fundamental ideas in biology and their uses today. Hailed by Philip Pullman as "a great communicator" who is also "as distinguished a scientist as there could be," Paul Nurse writes with delight at life's richness and a sense of the urgent role of biology in our time. With What Is Life? he delivers a brief but powerful work of popular science in the vein of Carlo Rovelli's Seven Brief (...) Lessons in Physics. Nurse takes readers on a wondrous journey through five fundamental biological ideas-the Cell, the Gene, Evolution by Natural Selection, Life as Chemistry, and Life as Information-introducing the scientists who made the most important advances and taking us into his own lab to give us a sense of the thrill of scientific discovery. In a final chapter, Nurse addresses biology's most pressing ethical issues (including gene-editing, genetic testing, and genetically modified crops), and he concludes with a stirring encomium to biology's role in tackling infectious disease. (shrink)

Life is all around us, abundant and diverse, it is extraordinary. But what does it actually mean to be alive? Nobel prize-winner Paul Nurse has spent his career revealing how living cells work. In this book, he takes up the challenge of defining life in a way that every reader can understand. It is a shared journey of discovery; step by step he illuminates five great ideas that underpin biology. He traces the roots of his own curiosity and knowledge (...) to reveal how science works, both now and in the past. Using his personal experiences, in and out of the lab, he shares with us the challenges, the lucky breaks, and the thrilling eureka moments of discovery. To survive the challenges that face the human race today - from climate change, to pandemics, loss of biodiversity and food security - it is vital that we all understand what life is. (shrink)

Zentrale Denkfiguren der von Wolfgang Klafki begründeten kritisch-konstruktiven Erziehungswissenschaft werden in diesem Buch aufgegriffen und in ihrem Innovationswert für die wissenschaftliche Pädagogik reflektiert. Namhafte Autorinnen und Autoren unterschiedlicher Subdisziplinen und Generationen vertiefen Klafkis Ansatz theoretisch wie methodisch und öffnen Problemstellungen, die bisher nicht bearbeitet worden sind.

In the yeasts Saccharomyces cerevisiae and Schizosaccharomyces pombe, the initiation of DNA replication is controlled at a point called START. At this point, the cellular environment is assessed; only if conditions are appropriate do cells traverse START, thus becoming committed to initiate DNA replication and complete the remainder of the cell cycle. The cdc2+ / CDC28+ gene, encoding the protein kinase p34, is a key element in this complex control. The identification of structural and functional homologues of p34 suggests that (...) it has a role in the control of DNA replication in all eukaryotes. The WHI1+, CLN1+ and CLN2+ gene products, identified in S. cerevisiae, are positive regulators that function at START and may interact with p34. Determining how passing the START control point leads to the initiation of DNA replication is a major outstanding challenge in cell cycle studies. (shrink)

Three major aspects of G1 regulation acting at START in fission yeast are discussed in this review. Firstly, progression towards S phase in the mitotic cycle. This is controlled by the activation of transcription complexes at START which cause cell cycle‐dependent activation of genes required for DNA synthesis. The second aspect is the regulation of developmental fate occurring during G1. Passage through START appears to inhibit sexual differentiation because the meiotic and mitotic pathways are mutually exclusive. This is brought about (...) because the meiotic pathway is inhibited by the same gene functions that are required for S phase onset. Thirdly, distinct checkpoint, or dependency, controls operate both pre‐ and post‐START in the mitotic cycle to inhibit mitosis in the absence of replicated DNA, and also to limit rounds of DNA replication to one per cell cycle. (shrink)

In this paper we argue that ‘informed’ consent in Big Data genomic biobanking is frequently less than optimally informative. This is due to the particular features of genomic biobanking research which render it ethically problematic. We discuss these features together with details of consent models aimed to address them. Using insights from consent theory, we provide a detailed analysis of the essential components of informed consent which includes recommendations to improve consent performance. In addition, and using insights from philosophy of (...) mind and language and psycholinguistics we support our analyses by identifying the nature and function of concepts (ideas) operational in human cognition and language together with an implicit coding/decoding model of human communication. We identify this model as the source of patients/participants poor understanding. We suggest an alternative, explicit model of human communication, namely, that of relevance‐theoretic inference which obviates the limitations of the code model. We suggest practical strategies to assist health service professionals to ensure that the specific information they provide concerning the proposed treatment or research is used to inform participants’ decision to consent. We do not prescribe a standard, formal approach to decision‐making where boxes are ticked; rather, we aim to focus attention towards the sorts of considerations and questions that might usefully be borne in mind in any consent situation. We hope that our theorising will be of real practical benefit to nurses and midwives working on the clinical and research front‐line of genomic science. (shrink)

Clinical bioethics is big business. There are now hundreds of people who bioethics in community and university hospitals, nursing homes, rehabilitation and home care settings, and some who play the role of clinical ethics consultant to transplant teams, managed care companies, and genetic testing firms. Still, there is as much speculation about what clinically active bioethicists actually do as there was ten years ago. Various commentators have pondered the need for training standards, credentials, exams, and malpractice insurance for ethicists engaged (...) in clinical consultation. Much of the discussion seems to accept an implicit presumption that all clinical ethics consultation practices look pretty much alike. But is this accurate? What do clinical ethicists do, how and where do they do it, and what kind of clinical ethics is useful in the hospital and in other settings? (shrink)

With a “big tent” understanding of bioethics, this dictionary provides definitions of 755 important terms drawn from a wide variety of contexts: medicine, nursing, behavioral health, forensic science, research ethics, public safety, social work, and epidemiology, on the one hand; bioethics, ethics, law, history, philosophy, and theology, on the other. Bioethical approaches and ethical categories are given their due, as are the major theoretical orientations. Terms from outside the USA, especially the UK, are in evidence. Many Greek and a few (...) Latin equivalents are provided; for example, “cloning.” Cross references abound. That’s Part 1. Part 2 offers single-paragraph introductions, 95 in all, to Historical Figures from a number of fields: medicine and nursing, dentistry and pharmacy, certainly; but there are also philosophers, scientists, environmentalists, public health pioneers, noteworthy psychologists and psychiatrists—along with many others. The religions are not neglected: important Christian thinkers are represented along with nine famous clinicians from the Islamic Golden Age. This resource offers the definitions of important terms and the identifications of historical figures that everyone interested in bioethics should have access to. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:You Can't Say "No" to That!(A "Difficult Patient" Story)Ingrid BergAs a sequela of COVID-19, my rural Wisconsin hospital has been jam-packed for months with patients for whom we routinely provide care and many for whom we do not. An exodus of health care workers and other constraints have made the transfer of critically ill patients very difficult. In this disquieting "new-normal" of our work life, we routinely must call (...) bigger cities throughout our state to find beds for complex patients.So, it was not surprising when a young patient, an IV drug user in sepsis from a heart infection, was admitted to me in the middle of the night. In less disheartening times, before the pandemic, this patient would have been transferred promptly to the big-city hospital. Now, though, the possibility of finding an open bed is next to impossible. Resigned, I placed admission orders, continued antibiotics and fluids, and crossed my fingers. Then the unexpected happened: a bed opened up, and we could send her at once!The patient had a harsh heart murmur. It was likely that a "vegetation" was clinging to the valve, between the right upper and lower chambers of her heart. A vegetation is a clump of debris, such as platelets, clotting proteins, and bacteria that is a menace to the body. Her chest imaging looked like her infection had already spread to her lungs.A definitive diagnosis for endocarditis requires a special ultrasound with a probe that goes down through the esophagus, a procedure performed by cardiologists. It's a serious infection, one that requires weeks of IV antibiotics and is best monitored by infectious disease specialists. Sometimes, cardiothoracic surgeons are called upon to strip away the infection at the site, depending on how badly the valve has been slayed or the size of the vegetation. My only recommendation for a young, otherwise healthy patient in this scenario, is transfer.All of these reasons for transfer were lolling around in my tired head when the night-time [End Page 14] nursing supervisor approached me and said, "We have a problem." When the patient was updated about the transfer, she balked: "She says she is tired and refusing to go," the supervisor began. "She doesn't feel like getting into an ambulance in the middle of the night and she doesn't care if her condition is life-threatening. She knows we can't force her to go and she will only talk about it again in the morning."The cartoon version of myself at that moment had bugged-out eyes, a dropped jaw, fists tight and clenched at my sides, and steam coming out of my head. I can look past a patient's self-neglect, poor medication adherence, abysmal communication, alcohol and drug addiction, and other crimes. But saying no to a bed at a tertiary care facility? Unacceptable!I marched down the quiet hallway and into her room. She was lying on her side, facing the door, one IV in a thin arm. I was confident I could reason with her once I explained the scarcity of beds and the medical necessity of transfer. But she was having none of it. I was calm until I could no longer maintain my cool: "You can't give up this bed!""Maybe in the morning," she insisted, yawning. "But not now. I am tired and want to rest!""But there might not be a bed in the morning," I countered. "And your infection can be life-threatening." (This is true, but we both knew she wasn't dying at this very moment.)"I am not going anywhere!" She raised her voice and then closed her eyes.And she was right. I had no choice but to keep her. I could not kick her out of the hospital because she was making a poor choice, and I was frustrated for having to manage the fallout of that decision. Giving her antibiotics and fluid boluses to bolster her blood pressure was certainly within my scope of practice. And fretting. Fretting is always within my scope of practice; not that my scope of practice matters when all the big... (shrink)

BackgroundIn cancer care, do not resuscitate orders are common in the terminal phase of the illness, which implies that the responsible physician in advance decides that in case of a cardiac arrest neither basic nor advanced Coronary Pulmonary Rescue should be performed. Swedish regulations prescribe that DNR decisions should be made by the responsible physician, preferably in co-operation with members of the team. If possible, the patient should consent, and significant others should be informed of the decision. Previous studies have (...) shown that physicians and nurses can experience ethical dilemmas in relation to DNR decisions, but knowledge about what ethical reasoning they perform is lacking. Therefore, the aim was to describe and explore what ethical reasoning physicians and nurses apply in relation to DNR-decisions in oncology and hematology care.MethodsA qualitative, descriptive and explorative design was used, based on 287 free-text comments in a study-specific questionnaire, answered by 216 physicians and nurses working in 16 oncology and hematology wards in Sweden. Comments were given by 89 participants.ResultsThe participants applied a situation-based ethical reasoning in relation to DNR-decisions. The reasons given for this were both deontological and utilitarian in kind. Also, expressions of care ethics were found in the material. Universal rules or guidelines were seen as problematic. Concerning the importance of the subject, nurses to a higher extent underlined the importance of discussing DNR-situations, while physicians described DNR-decisions as over-investigated and not such a big issue in their daily work.ConclusionThe study revealed that DNR-decisions in oncology and hematology care gave rise to ethical considerations. Important ethical values described by the participants were to avoid doing harm and to secure a peaceful and “natural” death with dignity for their dying patients. A preference for the expression “allow for natural death” instead of the traditional term “do not resuscitate” was found in the material. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Journey to WellnessRoberta PriceI should preface this by saying that as a child and early teen years I was lean, well within my weight range for my height of 5’3”. I was physically active as a snow skier, swimmer, hiker and biker. I started running in high school until I got pregnant at the age of 17 in 1988, but even then, my family and I had a gym (...) membership and I worked out with a trainer until my belly got too big and complications from pre–eclampsia forced me to bed rest the last four weeks of my pregnancy. I gained about 80 pounds, mostly water, during this time. Post pregnancy, I lost all my weight and resumed my active lifestyle of walking etc. It wasn’t until I got married in 1990 that I found my weight creeping up on me, slowly, every year. I was still active with three kids and a husband by then, but bad eating habits and cheap carbohydrates were not my friend.My efforts to return to leanness started a few years ago, about 2006. At that point, I weighed at least 200 pounds and I was not happy. Everyone knows the best way to lose weight is to exercise and watch what you eat, so I start daily walks. While walking I started having problems with my legs going numb to the point that I could not feel my feet hit the ground. At first I thought this feeling was due to a pinched nerve as a result of a single–vehicle car accident I was in earlier that year. Some days my legs would not bother me while walking and other days only a few steps would bring on the numbness. Also, I was susceptible to feelings of panic and a racing heart beat. My doctor at the time never once mentioned my weight being an issue. The nurse would write my weight on the chart, I would cringe as I waited for the lecture from my doctor about my weight to start. It never did. It was a strange, sort of “non–issue” with him as I had three kids so I was fat from that. My physician just said, “Lose the weight, I have no idea what is causing the numbness in your legs.”Fast forward to 2011, I am now under the care of a chiropractor in hopes of relieving the numbness that is happening all too frequently now. An ultrasound of my veins showed good blood flow so that ruled out a circulation issue. The chiropractor prescribed physical therapy to help ease my lower back pain hoping that would relieve the nerves I thought were pinched. I was prescribed high blood pressure medication by my doctor, with adverse side effects such as a nagging cough that would not go away—no matter how much cough medicine I consumed. It was during these sessions with my physical therapist that I was able to lose 10 pounds.There is a lot of self–talk in the life of an overweight or obese person. Everyday I woke up, knowing I had to lose weight. Every single time I looked in any mirror or saw any photo (which I was careful to be the photographer and not a subject as denial had become my best and worst friend). It was the subject of many a late night conversation with my husband, whom by the way, at his worst weight was 30 pounds over his preferred height to weight ratio. Not a single doctor I saw previous to this offered any hope for weight loss other than to shove a piece of paper at me telling me to eat these “healthy foods” listed. Since I was the family chef and chief purchaser of food, I was buying and eating vegetables, fruit, whole grains, and attempting to cut down on the processed foods—although, we were heavy eaters of potatoes, pastas, bagels, pizzas and other high carbohydrate foods. Over the years, [End Page 112] the most weight I had lost “counting calories” or portioning out “slow carbs” over “fast carbs” only afforded me a 15 pound loss, to be gained... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Transformation:Power in Persistence and PerspectiveTyler BendrickWe've got another meth napper," my resident stated. With an introduction like that, it is hard not to be immediately labeled as a "difficult patient." Being the only Spanish-speaking person on the team, I, a third-year medical student, became the primary point of contact for this severely injured patient. He was an only-Spanish-speaking, 36-year-old male admitted [End Page 7] to our trauma service (...) after he was hit by a truck while riding his bicycle. Unbeknownst to me at the time, the 14 days I spent caring for this man would become one of the most pivotal learning experiences of my medical school career. It changed not only how I understand and approach "difficult patients" but expanded my knowledge of the complexities and challenges of the current healthcare system and how we, as physicians and healthcare providers, can deliver the best care to patients with low health literacy and limited resources.So, what is a "meth napper?" I questioned. "Well, meth is a super stimulant," my resident explained. "When people are frequent meth users, they get used to functioning normally with high levels of stimulants in their body, reducing the normal regulation of wakefulness. When the amphetamine is removed (such as upon admission to the hospital), the body is left to fend for itself, and thus patients oftentimes sleep for 23 hours a day for about 3 to 5 days while their body works to detox and normalize hormones."As predicted, my new friend, "Joe," was napping when I first went to see him. Thinking back, the word "napping" does not accurately describe his level of somnolence. He was virtually unarousable, and I took to a sternal rub to wake him up at 5 a.m. after his traumatic exploratory laparotomy the night before. Once aroused, he was furious. "Estoy bien. Tengo dolor y tengo hambre," he grunted at me. (I am fine, and I am in pain and hungry!). "Ok, Joe," I replied in Spanish, "I am just going to do a quick exam and you can go back to sleep. We will give you medications for your pain. You had a big surgery on your intestines, so you cannot eat or drink right now. If everything goes well in the next couple of days and you start walking around, we can advance your diet." He begrudgingly let me examine him, never opening his eyes, and I left and went about my day.We continued this routine for five days. I would periodically check on him and usually found him sleeping. When awake, he refused to work with physical therapists, get up and walk or go to the bathroom, shower, use his spirometer, or converse with the nursing staff. He seemed completely disinterested in recovery. About day three, we slowly advanced his diet to clear liquids so he could quench his thirst. Sometimes his wife was there, and she would ask for updates, to which I could only reply, "We have to wait until he is more awake or willing to work with us." I was getting frustrated, as it seemed that his noncompliance was becoming his barrier to discharge.But on day six, everything changed. I went to check on Joe, and he was wide awake, vomiting, and irate. He shouted that he was in incredible pain, and his incision was wet. He was also complaining that he had not eaten in five days, and was insisting that we were starving him. Again, I calmly explained (as I had multiple times a day for the past five days) that his major abdominal surgery prevented us from feeding him until his intestines healed. We were giving him fluids and nutrition through his IV lines, so he was not starving to death. I rushed to get my resident to examine his oozing wound, and after a CT scan and an x-ray, we discovered what we feared: His wound had opened down to the fascia, "dehiscence," as it is called. On top of this, he now had a bowel obstruction, causing his vomiting. His lack of mobility for the past five days had slowed his... (shrink)

Martin was a twenty-nine-year-old anthropologist working on animism in Siberia when a bear leaped on her. He raked her with his claws, put her head into his mouth, and was about to crush her skull when she stabbed him with her ice axe. He loped off into the woods, carrying part of Martin's lower jaw and, if Martin is right, half of her soul—but leaving half of his soul in return. Martin lay bleeding in the snow. She managed to fashion (...) a tourniquet that slowed the bleeding from her leg. Miles away, a friend was fishing. He fell backward and blacked out. When he came to, he knew that something bad had happened to Martin.But was it bad?It certainly seemed so for a while. A Russian helicopter lifted her to hospital. Her wounds were treated, but the hospital seemed more brutal than the bear. She was strapped to the bed, unable to move her arms or legs. She wheezed through a tracheostomy tube. A malevolent nurse rammed food agonizingly into her with a syringe. Copulating doctors and nurses moaned and grunted in the side room next to her. Her jaw was roughly screwed together. On the plane back to France, the low cabin pressure reopened her scars. Her weeping mother dabbed at the blood with a tissue. In the French hospital, Martin took off her bandages in front of the mirror and wept “for my bear, for my old, lost face.”She had been invaded. She was now half-human, half-bear, a Siberian friend had told her: “He didn't want to kill you, he wanted to mark you. Now you are medka, she who lives between the worlds.” To be healed, she had to forgive the bear, for she would not otherwise forgive herself. At night she went “underground” to “speak to my bear.” Her head was “a ball scored with swollen red-claw marks and sutures. I am nothing like myself anymore, and yet I've never looked more like my own spirit; it has been imprinted on my body.”The invading bear had created a bridgehead into her. Other entities followed. The most immediately dangerous were bacteria and surgical scalpels. The surgeons did not know what they were toying with: “My body has become a territory where Western surgeons parley with Siberian bears. Or rather, where they try to establish communication.”The surgeons never did establish communication, and so their sort of healing would not work. Martin knew that she would only find healing in her “lair” in the Siberian forest, from those “who know bears and the questions they bring with them, who still speak with them in their dreams, who know that nothing happens by chance.” And so back she went.There was no epiphany. But there was the quiet healing that comes from recruiting all the agencies in the tundra; in distilling agency itself and dripping it over her wounds. And asking the right questions can heal too. The right questions are questions that are too big for answers.What is this book about? Martin is clear that what did not happen was that “a bear attack[ed] a French anthropologist somewhere in the mountains of Kamchatka.” What did happen was that “a bear and a woman [met] and the frontiers between two worlds implode[d].... Mythical time meets reality; past time joins the present moment; dream meets flesh.”Eye of the Wild poses an unnerving set of fundamental questions about what it means to say, as we all blithely do: “I am”—about how many souls we can accommodate, how we can broker a respectful or at least tolerable conversation between them; about our porosity to the cosmos we comfortingly assert is out there. This book is plangent, frigid, and chilling. It is a mosaic of jagged fragments that, viewed in the right light, perhaps add up to the scarred face of a young woman, all the lovelier for the scars. Yet the fragments do not add up to a proposition, for this is a book about what happens when you are brave enough to go to a place where no proposition could ever land. (shrink)

Being a stranger has become a global definition due to the migrations caused by the wars and unemployment in the Middle East and the perceptions of Islamophobia and Islamic terrorism prevailing in the West. In Alfred Schutz’s essay The Stranger, he deals with this issue in terms of orientation and adaptation problems and gives information about this concept by making use of different examples. Mahir Guven also rehandles the concept of the stranger in his novel Older Brother (Grand Frère) by (...) building on the story of an immigrant family. Older Brother is a contemporary and political novel. It tells of two brothers in their thirties who grew up in a multicultural family (Turkish mother, Kurdish father, and two brothers; one is a half‑Syrian taxi driver, and the other is a half‑French surgical nurse) in the suburbs of Paris. The novel interrogates concepts such as nationality, belonging, family ties, culture, identity, immigration, and foreignness through the eyes of the characters. Starting from the problem of being a stranger, which has become a big problem with the effect of increasing immigration movements, we will try to examine the novel Older Brother from Alfred Schutz’s point of view approach to this matter. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:An Epidemic of Difficult PatientsKeva SouthwellAs the opioid epidemic marches on, we have all become familiar with a particular breed of "difficult patient," the intravenous drug user. Most teams try to get through these admissions with as few interactions as possible. Nurses will tell you how much they hate caring for these patients, often citing "they did this to themselves" as they experience prolonged admissions due to infections resulting (...) from Intravenous Drug Use (IVDU). Most services try to get out of admitting these patients, saying they are more appropriate with infectious disease, cardiology, or "anywhere but with me." These patients often use drugs in the hospital, threaten to leave AMA, and are dangerous, liable to assault or abuse the very staff trying to help them. The general consensus is that taking care of these patients is a dirty job … why do I have to do it?That's where I come in. It's a dirty job … and that's exactly why I do it. I run a unique service, where my preferred patients are those admitted for 6–8 weeks of IV antibiotics to treat their endocarditis. Some of these patients survive after discharge, but most don't. I know this. But it's my job to help them anyway. It just turns out that in these cases, help doesn't always look the way you think it will.In a perfect world, having a life-threatening infection would be the rock bottom these young people need to embrace a new way of life. Unfortunately, this world is far from perfect. Just as having diabetes doesn't make you stop wanting junk food, having endocarditis does not make you stop wanting drugs. In fact, it can be the opposite. [End Page 26] Drugs are often the coping tool these patients turn to. Happy? Use drugs. Sad? Use drugs. Scared? Use drugs. That's why it's hard. Addiction defies logic; it can be cunning, baffling, and powerful. Until you understand addiction, you'll never really find a way to treat these patients, let alone a way to enjoy treating them.We all have patients who change things for us. They shift our perspective, make us view our practice, our patients, and ourselves differently; patients who teach us the lessons not learned in school. I will never forget Jack, one of those "difficult patients." He taught me how to care for people who really can't be medically helped. It's a lesson that can take years to learn: You've got to let go of the outcome, and some solutions don't look the way you think they should. In this way, he helped me continue in this difficult work.I was a nearly new hospitalist, having just moved into this work from outpatient addiction care. Jack was a young man, 32 years old. He had presented to our hospital with endocarditis of the aortic and tricuspid valves secondary to IVDU. He was referred to my service when he was ineligible for valve replacement due to septic emboli in his brain and subsequent micro hemorrhage. The surgery team wanted him to recover from these events before considering surgical treatment.Jack was a big guy, over 6'2", with a weight to match. He was covered in tattoos—his back, arms, chest, and neck—not an inch was bare. His physical presence might be considered intimidating. Jack was a man of few words: he complained of very little, was often asleep during medical visits, never really left his room, and had no visitors. About four days after his arrival, nursing became concerned about illicit drug use. Despite the fact he had no orders for narcotics or other sedating meds, he was sleeping all the time. His drug screens were negative. Despite the lack of specific evidence, I was asked to take measures to ensure he was not using illicit drugs, which included placing him on a contract and ordering 1:1 observation.His fatigue was concerning, though not for drug use. A repeat ECHO showed that his aortic insufficiency was worsening. His tricuspid insufficiency was very bad from the start. His belly began to swell, followed by his... (shrink)

BackgroundThe Life Extension Medical Decision law enacted on February 4, 2018 in South Korea was the first to consider the suspension of futile life-sustaining treatment, and its enactment caused a big controversy in Korean society. However, no study has evaluated whether the actual implementation of life-sustaining treatment has decreased after the enforcement of this law. This study aimed to compare the provision of patient consent before and after the enforcement of this law among cancer patients who visited a tertiary university (...) hospital's emergency room to understand the effects of this law on the clinical care of cancer patients.MethodsThis retrospective single cohort study included advanced cancer patients aged over 19 years who visited the emergency room of a tertiary university hospital. The two study periods were as follows: from February 2017 to January 2018 (before) and from May 2018 to April 2019 (after). The primary outcome was the length of hospital stay. The consent rates to perform cardiopulmonary resuscitation (CPR), intubation, continuous renal replacement therapy (CRRT), and intensive care unit (ICU) admission were the secondary outcomes.ResultsThe length of hospital stay decreased after the law was enforced from 4 to 2 days (p = 0.001). The rates of direct transfers to secondary hospitals and nursing hospitals increased from 8.2 to 21.2% (p = 0.001) and from 1.0 to 9.7%, respectively (p < 0.001). The consent rate for admission to the ICU decreased from 6.7 to 2.3% (p = 0.032). For CPR and CRRT, the consent rates decreased from 1.0 to 0.0% and from 13.9 to 8.8%, respectively, but the differences were not significant (p = 0.226 and p = 0.109, respectively).ConclusionAfter the enforcement of the Life Extension Medical Decision law, the length of stay in the tertiary university hospital decreased in patients who established their life-sustaining treatment plans in the emergency room. Moreover, the rate of consent for ICU admission decreased. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Calling Obesity a Disease Is A Terrible DecisionMoose FinklesteinFactsThe medical world struggles to see the difference between health and body weight. It is still mostly combined with the strong belief that there is no way a fat person can be fit and healthy. Despite repeated studies and work to show differently, this prejudice remains. This has become part of what I call “Everyone Knows” pseudoscience, where data that have (...) no scientific basis become “fact” due to constant repetition.Obesity is already the cause of great stigma in our society. Fat people are considered “ugly,” fat jokes are acceptable in everyday life, and being called ‘fat’ is, to many, as big an insult as a racial slur. Fat prejudice can approach the levels of racial prejudice (Puhl, Andreyevea & Brownell, 2008). Fat children are bullied, sometimes to the point of suicide. Some studies have found children as young as five trying to diet for being fat, no matter their actual weight. Fat people are more likely to be unemployed or underemployed, and there are prejudicial beliefs that fat workers are more problematic, despite research saying otherwise (Roehling, Roehling, & Odland, 2008).Obesity is seen by the masses as something people choose. However, science disagrees. There has long been a link between depression and obesity. Mental health is tightly tied to obesity, where those who experience weight discrimination are more likely to gain weight, although unhealthy behaviours such as binge eating and exercise avoidance are sometimes seen as a coping mechanism (Sutin & Teracciano, 2013).It has been reported in a number of journals that 90–95% of the people who lose weight regain the weight within 10 years (Mann et al., 2007; Miller, 1999). “Everyone Knows” claims that this is because people go back to bad habits. Science, however, says that there are complex ways the body wants to regain the weight (Sumithran & Proietto, 2013; Sumithran et al., 2011). Worse, dieting may contribute to obesity. Adolescent girls who diet are at 324% greater risk for obesity than those who do not diet (Stice, Cameron, R. P., Killen, J. D., Hayward, C. & Taylor, C. B. 1999). Weight loss dieting may cause other health problems as well, such as immune system problems (Shade ED, et al. 2004).In the medical world, doctors are encouraged to talk to patients about their weight. Every fat person has heard, “What are we going to do about your weight?” The “we” is supposed encourage the patient to feel that the doctor is on the patient’s side in their battle. Yet what many patients hear is, “I don’t see you as a patient, I see you as fat.” Science says that the higher a patient’s BMI the less respect a doctor has for the patient (Huzinga, Cooper, Bleich, Clark, & Beach, 2009).Horror stories about fat people trying to get decent health care are everywhere. For a good example, see Bruce Taylor Seeman’s piece, “The Perils of Obesity May Include the Doctor” (2006). [End Page E1] There are many blogs and stories on the internet about the way patients are not just shamed for their weight, but actively bullied by medical professionals. One blog, The Well Rounded Mama (wellroundedmama.blogspot.com), discusses the bias of doctors against pregnant fat women, who are told things like, “You cannot have a healthy baby when you are this fat” and encouraged to abort. Tales from people told that their weight is the cause for everything and anything can be found on sites like First Do No Harm (fathealth.wordpress.com). Reading blogs by medical professionals can show the disdain they have for fat people. In one, an emergency room nurse declared that all fat diabetics have poor control, based solely on perceptions from her job. Comments were mostly other nurses agreeing with how “disgusting” fat people are to have to deal with. However, Yale University’s Rudd Center for Food Policy & Obesity not only recognizes the problem but aims to help medical professionals eliminate the bias.If obesity becomes a disease, weight loss surgery (WLS) becomes a bigger gold mine. Medical insurance will be more likely to cover weight loss surgery. WLS is an ever-changing target: there... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Importance of Respect in Patient CareSue GibsonI have been a state-tested nurses aide (STNA) for 32 years. When I get up to go to work, I always start out with a positive attitude.After I clock in for my shift, I go to my assigned floor to start my day. I gather up all my paperwork that is necessary and I'm off and running.I feel the best way to make (...) a resident feel comfortable in their surroundings is to have the resident help in making as many decisions in their day as possible. Decision-making helps a resident feel at home. As an STNA, I am there to help them if a resident needs any kind of assistance during the shift that I am working. One of the first priority questions of the day concerns their meals. The resident selects the lunch and dinner choice. If a resident is not sure what they would like to choose for their meals, I help them choose from what is available to them. I write their selection down for the dietary department and I always thank the resident and smile as I leave the area. Now that they know what their choices are for the day, they have something to look forward to. [End Page 139]Another decision a resident has for the day is their choice of what they would like to wear for the day. He or she may have a favorite article of clothing they like to wear. They may like it because it may be their favorite color or something they really feel comfortable in. I again thank the resident on their decision-making and helping me make their day. I compliment the resident on how nice and neat they look.Showering is the next big thing of the day. Some residents love to get in the shower, while on the other hand, some residents hate to hear the word shower, let alone get into it. Some residents need a lot of encouragement to take a shower. I give the resident a choice as to when they would like to shower. All the residents have a regular shower day. If the resident is scheduled for a shower and would like to take the shower before going to bed, I tell the nurse and the shower is rescheduled for the afternoon shift. The decision is made by the resident and the resident is more likely to follow through with their decision.Activities are scheduled on a daily basis. When the activity is announced over our intercom system, I ask the residents if they would like to attend the activity and sometimes I take them to the floor the activity is being held on.Every Thursday there is a scheduled outing for either breakfast or lunch. It is my job on these outings to go with the activity staff and tend to the residents' needs, if necessary. We go out to a public restaurant and the resident chooses what they would like to eat. If they need help, I am there to help them. I'll ask them, "What are you hungry for?" or, "What sounds good to you?" I read the menu for them and give the residents time to choose what they would like. I have residents who need the food cut up for them because they cannot see well. I tell them where what food is on their plate. I sit by the resident who may need assistance or help in eating and drinking. I feel this outing is important to every resident who goes. Whether it is going out to eat, on a ride, or even to the doctor, they need to feel they have the freedom to choose to do this.It is not unusual to be physically or verbally abused by a resident on a daily basis. A resident might be angry over some little thing and the STNAs are the people they take their anger out on. I take into consideration that the residents are here for a reason, so I never take their words or actions as a personal attack on me.Staying in bed an entire shift... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Invisible ChildrenMaureen KelleyИсчезаю в весне,в толпе,в лужах,в синеве.И не ищите.Мне так хорошо...I fade into spring,or into a crowd,or into a puddle,sometimes into the blue.There's no sense in looking for me.I feel fine...—¾"Absentee" by Arvo Mets"You have to go through Lesha to get to Danil," Alexandra told me. Lesha was a small but unmoving dog with matted hair and a fierce growl. The dog was pressed against the little (...) boy, who looked no more than three or four years old. Alexandra later told me he was eight. Danil was wearing a Spider Man shirt that was four sizes too big and came down to his feet and mismatched sandals. He was huddled against his dog not only for security but warmth. His tiny arm circled Lesha's neck and he looked at me with a mix of curiosity and caution. I knelt and put my hand out for Lesha to smell me. Apparently I didn't pass the smell test. The dog didn't budge from his post. We stood like that for a long time, at the base of the steps to the shelter. I tried the few Russian words I had learned while visiting as a volunteer. The dog didn't understand my broken Russian, or pretended not to, but I managed to get a shy smile from Danil.Alexandra, a nurse volunteer at the shelter, eventually mediated the standoff by giving Lesha, the dog, a cookie. I introduced myself to the little boy. And just like that, he leaned up against me and put both arms around my legs. It didn't matter that I was a stranger, and a stranger who spoke terrible Russian. "Spidey" was an affectionate little guy. He gripped my hand while Alexandra led us up the steps and Lesha followed close behind. Inside was a small room, warm and full of color. One wall was covered in kids' drawings. Another had public health posters in Russian, some with instructions for condom use, others on literacy. There were about fifteen kids in the shelter that afternoon. The young ones were drawing pictures at a low table. Two teenage boys were hunched over a small TV playing a video game. There was only one teenage girl, Irina. She was cooing at the little kid's drawings, showing one girl how to draw a princess. Alexandra said quietly to me, "Most of the teenage girls are only here in the morning. The rest are back at work right now." I found out later "back at work" meant on the streets as sex workers. This city was frequented by businessmen and itinerant workers heading to the factories or lumber mills in the North. The best money for homeless girls was in prostitution. Danil unwrapped himself from me and ran over to the two older boys playing video games. One put his controller down long enough to pull Danil into his lap. The three boys stared intently as Super Mario hopped from mushroom to magic cloud, golden coins spinning above his cartoon head.To the right of the main room was a closet-sized office for the shelter director, Anya, a pediatrician who donated her time to running the shelter for homeless and orphaned youth living on the streets. Alexandra and I stood in the doorway waiting for Anya to finish a phone conversation. Her desk was covered in papers. Behind her were photos of the kids who had "graduated" from the streets. There were cards and letters pinned to a cork board. When [End Page E4] she finished, Anya greeted us with bear hugs and showed us to the clinic area. Next to her office was a small bathroom with a shower and tub. She explained that bath days were on Wednesdays. Around back, with a separate entrance was the small clinic space. The outside metal door had a sliding window that you see at some nightclubs. They ran a needle exchange program out of that door. It was funded for street youth, but from time to time they would get adult addicts. Anya was adamant that this side of the clinic remain separate from the central space for the children. In reality the distance... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Obesity as Disease:Definition by DesperationJeremy ShermakI hated removing my shirt. Each visit to my doctor’s office, following a blood pressure and temperature check, the nurse would instruct me to take off my shirt so the doctor could examine me further. She would then leave the room. I remained perched atop the exam table, now half exposed, and a mirror on the wall would not leave me alone. In (...) the reflection, I saw my oversized breasts and “fat roll” oozing out from my pants, hiding my belt. I tried to straighten my back—breathe in, no wait, breathe out—to resculpt the appearance, but it did nothing. I hated myself. Soon, a gentle knock at the door would interrupt the loathing and I’d shake hands with my doctor.I have been obese for the majority of my life—from childhood until I turned 34, when shortly thereafter, I had gastric bypass surgery. Since that time, I have lost 155 pounds and now write this at a comfortable, healthy 180 pounds. That said, my mind remains “obese”. My thinking remains shrouded deep within the obese personality that I embodied for all of those years. I still automatically walk to the big–and–tall section of clothing stores; I don’t recognize the 34–waist pants when they come [End Page 114] out of the dryer; I’m not used to seeing my ribs; and I’m still terrified of that exam room mirror.Upon hearing the news that the American Medical Association (AMA) now classifies obesity as a disease, my initial reaction was that of relief. My recent success was due in large part to the discovery and treatment of hindering endocrinological issues. My history—like repeatedly slamming head–long into a brick wall—suggests that these medically verified roadblocks have existed for some time. Despite my efforts, I didn’t stand a chance.If anyone were a “poster child” for obesity as a disease, it would be me. The lifelong sparring with my weight had its ups and downs; I worked very hard to maintain or lose weight with mixed results. I lost 85 pounds my freshman year of college by running and fervently watching my portions. I kept that weight off for a good five years before the summer of 2003, when I started gaining weight very quickly. I gained 25 pounds in each month of June and July that year, despite maintaining my usual eating habits and running schedule. I soon lost faith. I felt as though I was up against forces that I could not control and I began to forget about losing weight. I didn’t binge, but I didn’t eat well. By 2008, my weight had reached 375 pounds—an all–time personal high.Following a bad relationship and seeking rejuvenation, I embarked on a diet that summer like I’ve never tried before. I cooked everything naturally—from regular dishes like stuffed peppers all the way to condiments like ketchup. It was a militant effort on my part. I lost 50 pounds that summer and felt that I was well on my way back to the body that once felt so comfortable. It was at that point where I hit a wall. I could not get past 321. I can still see that number staring back at me on the scale. It was frustrating. I felt I had done all I could. That’s when I visited a doctor who ran some tests that revealed problems with my hormones and metabolic systems.As it turned out, I had a tumor on my pituitary gland. This may have been the issue all along. That led to low testosterone, which had a really negative impact on my weight loss efforts. After thorough consideration, I decided to have gastric bypass surgery to “reset” my hormones and get a “boost” in my weight loss efforts. It worked.In my particular circumstance, I could view obesity as a disease because its causes, for the most part, were not a result of conscious lifestyle choices. I had no control over the pituitary tumor. However, I know that I could have done more to limit my... (shrink)

Big Ideas for Little Kids includes everything a teacher, a parent, or a college student needs to teach philosophy to elementary school children from picture books. Written in a clear and accessible style, the book explains why it is important to allow young children access to philosophy during primary-school education. Wartenberg also gives advice on how to construct a "learner-centered" classroom, in which children discuss philosophical issues with one another as they respond to open-ended questions by saying whether they agree (...) or disagree with what others have said. (shrink)

Research on moral distress has paid limited attention to nurses’ responses and actions. In a survey of nurses’ perceptions of moral distress and ethical climate, 292 nurses answered three open-ended questions about situations that they considered morally distressing. Participants identified a range of situations as morally distressing, including witnessing unnecessary suffering, being forced to provide care that compromised values, and negative judgments about patients. They linked these situations to contextual constraints such as workload and described responses, including feeling incompetent and (...) distancing themselves from patients. Participants described considerable effort to effect change, calling into question the utility of defining moral distress as an “inability to act due to institutional constraints” or a “failure to pursue a right course of action.” Various understandings of moral distress operated, and action was integral to their responses. The findings suggest further conceptual work on moral distress and effort to support system-level change. (shrink)

In this paper, we discuss several problems with current Big data practices which, we claim, seriously erode the role of informed consent as it pertains to the use of personal information. To illustrate these problems, we consider how the notion of informed consent has been understood and operationalised in the ethical regulation of biomedical research (and medical practices, more broadly) and compare this with current Big data practices. We do so by first discussing three types of problems that can impede (...) informed consent with respect to Big data use. First, we discuss the transparency (or explanation) problem. Second, we discuss the re-repurposed data problem. Third, we discuss the meaningful alternatives problem. In the final section of the paper, we suggest some solutions to these problems. In particular, we propose that the use of personal data for commercial and administrative objectives could be subject to a ‘soft governance’ ethical regulation, akin to the way that all projects involving human participants (e.g., social science projects, human medical data and tissue use) are regulated in Australia through the Human Research Ethics Committees (HRECs). We also consider alternatives to the standard consent forms, and privacy policies, that could make use of some of the latest research focussed on the usability of pictorial legal contracts. (shrink)

Reacting against the dominance of obligation-based moral theories in both general and nursing ethics, the author proposes a 'strong' (action-guiding) account of a virtue-based approach to moral decision-making within contemporary nursing practice. Merits and criticisms of obligation and virtue-based approaches to morality are identified and examined. One of the author's central premises is that the notions of moral goodness and badness carry more moral weight than the traditionally important notions of moral rightness and wrongness. Therefore, the author argues that in (...) order to deliver morally good care, it is vital to consider the kind of nurse one is and this means examining one's moral character. This book will be rewarding reading for a wide range of readers including clinical nurses, nurse educators and nurse ethicists; indeed, anyone interested in morality and ethics and the work of nurses will find this book stimulating reading. (shrink)

In Big Gods, Norenzayan (2013) presents the most comprehensive treatment yet of the Big Gods question. The book is a commendable attempt to synthesize the rapidly growing body of survey and experimental research on prosocial effects of religious primes together with cross-cultural data on the distribution of Big Gods. There are, however, a number of problems with the current cross-cultural evidence that weaken support for a causal link between big societies and certain types of Big Gods. Here we attempt to (...) clarify these problems and, in so doing, correct any potential misinterpretation of the cross-cultural findings, provide new insight into the processes generating the patterns observed, and flag directions for future research. (shrink)