This paper brings together ideas from two perspectives on ethics and health promotion. A discussion of the ethical dimension of the health promotion practice of community nurses is set in the wider context of health policy, with particular reference to health gain and individual responsibility. It is widely held that nurses have a key role to play in health promotion and that this is particularly the case for nurses working in primary health care. This (...) assumption is reinforced by policy documents from the World Health Organization, the Department of Health and statutory bodies such as the United Kingdom Central Council for Nursing, Midwifery and Health Visiting. The approach of many nurses to health promotion has tended on the one hand to be somewhat naive and on the other to be authoritarian and didactic; there has been little discussion in the nursing literature of the ethical aspects of health promotion. However, recent developments in nurse education, such as Project 2000 and the consequent changes to preregistration programmes, have resulted in increased attention to both ethics and health promotion within the curriculum. (shrink)

Values‐based practice is deemed essential for healthcare provision worldwide. In England, values‐based recruitment methods, such as multiple mini interviews (MMIs), are employed to ensure that healthcare students’ personal values align with the values of the National Health Service (NHS), which focus on compassion and patient‐centeredness. However, values cannot be seen as static constructs. They can be positively and negatively influenced by learning and socialisation. We have conceptualised students’ perceptions of their values over the duration of their education programme (...) as a ‘values journey’. The aim of this hermeneutic longitudinal focus group study was to explore the ‘values journey’ of student nurses and midwives, recruited through MMIs, across the 3 years of their education programme. The study commenced in 2016, with 42 nursing and midwifery students, originally recruited onto their programmes through multiple mini interviews. At the third and final point of data collection, 25 participants remained. Findings indicate that students' confidence, courage and sense of accountability increased over the 3 years. However, their values were also shaped by time constraints, emotional experiences and racial discrimination. We argue that adequate psychological support is necessary as healthcare students embark on and progress through their values journey, and propose a framework for this. (shrink)

Background:An understanding of the ethical concerns encountered by visiting nurses in the community is needed. Yet, there is a lack of research on this topic.Objectives:The purpose of this study was to explore the ethical concerns that visiting nurses experience when caring for vulnerable older people living in a community.Design and sample:A qualitative thematic analysis was used to explore the nature of the ethical issues experienced by visiting nurses (N = 13) who care for vulnerable older people, over (...) 65 years of age, in a South Korean community.Methods:In-depth interviews were conducted with visiting nurses. Qualitative thematic analysis was used to explore the main themes of the phenomenon.Ethical considerations:This study was approved by the Institutional Review Board of Chung-Ang University Bioethics Committee in South Korea.Results:Four ethical themes emerged from the qualitative data: (a) quantitative performance rather than quality care, (b) clients being invisible, (c) tuning the level of the relationship with clients, and (d) facing the visiting nurses’ own limitations.Conclusion:This study provides a theoretical basis to understand the ethical aspects of visiting nurses’ interactions with clients, which should facilitate the development of ethical guidelines for visiting nurses to use in making ethical decisions in their practice. (shrink)

Background: As a normative theory, care ethics has become widely theorized and accepted. However, there remains a lack of clarity in relation to its use in practice, and a care ethics framework for practice. Maternity care is fraught with ethical issues and care ethics may provide an avenue to enhance ethical sensitivity. Aim: The purpose of this scoping review is to determine how care ethics is used amongst health professions, and to collate the information in data charts to create (...) a care ethics framework and definition for midwifery practice. Method: The scoping review was conducted according to the Preferred Reporting Items for Scoping reviews (PRISMA-ScR) and Joanna Briggs Institute (JBI) recommendations. The search was applied to the databases CINAHL, MEDLINE, PschInfo and Pubmed which were searched in September 2019 and again in July 2021. The inclusion criteria were guided by the mnemonic for search terms: Participants, Concept, and Context (PCC) and included variations of health care professionals, care ethics and utilization. The search was limited to qualitative studies published in English between 2010 and 2021. A data extraction tool was used to extract and synthesize data into categories. The articles were screened for eligibility by title, abstract and full text review, by two independent reviewers. Ethical Considerations: The scoping review was guided by ethical conduct respecting authorship and referencing sources. Results: Twelve of the initially identified 129 studies were included in the scoping review. Data synthesis yielded four categories of care ethics use by health professionals: relationship, context, attention to power and caring practices. In combination, the evidence forms a framework for care ethics use in midwifery practice. Conclusion: Care ethics use by health professionals enhances ethical sensitivity. A framework and definition for care ethics for midwifery practice is proposed. This review will be of interest to midwives and other health practitioners seeking to enhance ethical sensitivity. (shrink)

This book describes in detail the important issues in these professions, accountability, standards of conduct, and the framework of the disciplinary process, ...

It is important to define and practice ethical rules and codes for professionalisation. Several national and international associations have determined midwifery ethical codes. In Turkey, ethical rules and codes that would facilitate midwifery becoming professionalised have not yet been determined. This study was planned to contribute to the professionalisation of midwifery by determining national ethical values and codes. A total of 1067 Turkish midwives completed the survey. The most prevalent values of Turkish midwives were care (...) for mother–child health, responsibility and professional adequacy. The preferred professional codes chosen by Turkish midwives were absence of conflicts of interest, respect for privacy, avoidance of deception, reporting of faulty practices, consideration of mothers and newborns as separate beings and prevention of harm. In conclusion, cultural values, beliefs and expectations of society cannot be underestimated, although the international professional values and codes of ethics contribute significantly to professionalisation of the midwifery profession. (shrink)

This article provides a theoretical critique from a particular ‘ideal type’ ethical perspective of professional codes in general and the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) Code of professional conduct (reprinted on pp. 77-78) in particular. Having outlined a specific ‘ideal type’ of what ethically informed and aware practice may be, the article examines the extent to which professional codes may be likely to elicit and engender such practice. Because of their (...) terminological inexactitudes and confusions, their arbitrary values and principles, their lack of helpful ethical guidance, and their exclusion of ordinary moral experience, a number of contemporary professional codes in health and social care can be arraigned as ethically inadequate. The UKCC Code of professional conduct embodies many of these flaws, and others besides. Some of its weaknesses in this respect are anatomized before some tentative suggestions are offered for the reform of codes and the engendering of greater ethical awareness among professionals in the light of greater public ethical concerns and values. (shrink)

This paper enquires into the nature and the extent of the obligations of nurses. It is argued that nurses appear to be obliged to undertake supererogatory acts if they take clause one of the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) Code of Professional Conduct seriously (as, indeed, they are required to do). In the first part of the paper, the nature of nursing obligations is outlined, and then the groups and (...) individuals to whom nurses have obligations are identified. Following a brief discussion of the moral foundation of the nurse's obligations to her/his employer, a common conflict of obligations is identified. Then a distinction is drawn between ordinary and extraordinary moral standards. Appreciation of this is necessary for an understanding of the criterion of what constitutes a supererogatory act. By the definition of supererogatory acts proposed below, it is suggested that actions such as whistleblowing satisfy that definition. (shrink)

Background More than one in 10 of all prisoners in England and Wales are Foreign Nationals. This article discusses whether the research applications to one London prison are aimed at understanding a prisoner population characterised by significant multinational and multilingual complexity. Methods We studied all accessible documents relating to research undertaken at a women's prison between 2005 and 2009 to assess the involvement of Foreign National prisoners and women with limited English. The source of information was prison research (...) applications and protocols. We also looked at available final research reports and journal articles. Results Two key findings emerged from this study. First, studies at this prison frequently excluded Foreign National prisoners and women with limited English. Second, Foreign National prisoners were often clustered as a homogeneous category in the research reports reviewed. This is despite their diverse cultural backgrounds, their variable immigration status and their differing competence in English, all of which affect their lives. Conclusions The failure to include and/or identify social subgroups of the population can undermine the value of research, including, in the case of the study prison, funded health research. This can compromise associated needs assessments and service delivery, particularly important in already disadvantaged populations; this may encourage and/or perpetuate a range of health inequalities. There is a pressing need to examine cultural exclusion in other health and criminal justice settings, to assess the ways in which—and the extent to which—such exclusion may compromise the merit of proposed and completed health and social research. (shrink)

BROOKS J and RAFFERTY AM. Nursing Inquiry 2010; 17: 142–150Education and role conflict in the health visitor profession, 1918–39Health visiting was the public health profession in the UK, which arose during the Victorian period to support and supervise the mothers of the nation. The health visitor was expected to teach the new mothers hygiene, infant feeding and diet, help them in the home when necessary and then report back to the Medical Officer for Health. (...) Her role therefore was multifaceted and required education and training from a number of differing bodies. She needed nursing skills to help with the practicalities of observation and home care, sanitary knowledge to ensure that the buildings were safe and training in law and epidemiology. In order to fulfil these professional requirements, by the middle of the twentieth century the health visitor was expected to be a nurse by background, be educated for health visiting in a university and understand community medicine. These differing and sometimes opposing requirements meant that the health visitor was often caught in-between conflicting ideologies. It is this idea of ‘in-betweenness’ from the work of the anthropologist Marilyn Strathern and its relation to the work and education of the health visitor that this article will focus. (shrink)

Violations of ethical conductThis article is about torture, power and the breach of ethical conduct among military doctors, nurses and medics in the “War on Terror”. Violations of ethical conduct have been widely recounted in academic and non-academic journals and reports.1 This paper is also a call to international boards of doctors and nurses to intervene directly to stop abuses undertaken by US military healthcare providers under the guise of the War on Terror. With evidence growing that US military and (...) security services are actively engaged in the ill treatment, torture and deaths of suspects, details about the participation of healthcare professionals in such unlawful and unethical activities remain for the most part timidly accounted for. But according to current literature on this topic, there is increasing evidence that US doctors, nurses and medics have been complicit in torture and other unethical activities in Afghanistan, Iraq and Guantanamo Bay .2–4The US government has inadequately dealt with these facts. Senior officials in the Bush administration who have played a major part in conducting the War on Terror have been either promoted or asked to remain in their posts. More seriously, despite worldwide condemnation of the reality behind the photos, allegations of torture continue at Guantanamo Bay, Cuba.5 The graphic and appalling nature of several photographs are by no means the only evidence of abuses conducted by the US on its own territory and abroad. But the complicity of healthcare professionals in many venues , such as in capital punishment procedures in the US, exacerbates the already disturbing extent of bio-political abuses by the US government.Doctors and nurses often top the polls as caring and trustworthy professionals.6 Indeed, so strong …. (shrink)

Medical malpractice has attracted the attention of people and the media all over the world. In Turkey, malpractice cases are tried according to both criminal and civil law. Nurses and midwives in Turkey fulfill important duties in the distribution of health services. The aim of this study was to reveal the legal procedures followed in malpractice allegations and malpractice lawsuits in which nurses and midwives were named as defendants. We reviewed 59 nursing and midwifery lawsuits reported to (...) the Higher Health Council between 1993 and 1998. Health professionals were held liable in 59% of the lawsuits. Midwives had the highest percentage of malpractice liability (52%), followed by physicians (29%) and nurses (19%). To reduce potential liability, nurse education should be improved, a nursing malpractice law should be enacted, and instructions for nursing procedures should be formulated. (shrink)

In this article we illustrate, and argue for, the importance of researching the social context of health professionals’ ethical agendas and concerns. We draw upon qualitative interview data from 20 nurses working in two occupational health sites, and our discussion focuses mainly upon aspects of the shifting ‘ethical context’ for those nurses with a health promotion remit who are working in the British National Health Service. Within this discussion we also raise a number of potentially (...) substantive issues, including the risks of colluding in ‘double standards’, and the tensions between the practitioner and managerial roles in nursing. Overall, we hope to pose questions about the best ways to understand the ethical agency and responsibilities of health professionals. (shrink)

Reflection is widely recognised as an invaluable tool in health care, providing fresh insights which enable practitioners to develop their own practice and improve the quality of their care. This book introduces the practitioner to the concept of 'Guided reflection', an innovative research process in which the practitioner is assisted by a mentor (or 'guide') in a process of self-enquiry, development, and learning through reflection, in order to become fully effective. Guided reflection is grounded in individual practice, and can (...) provide deeply meaningful insights into self-development and professional care. The process results in a relexive narrative, which highlights key issues for enhancing health care practice and professional care. This book uses a collection of such narratives from everyday clinical practice in nursing, health visiting and midwifery to demonstrate the theory and practicalities of guided reflection and narrative construction. These narratives portray the values inherent in caring, highlight key issues in clinical practice, reveal the factors that constrain the quest to realise practice, and examine the ways practitioners work towards overcoming these constraints. (shrink)

In this article it is argued that there are barriers to effective and non-discriminatory practice when mentoring overseas nurses within the National Health Service (NHS) and the care home sector. These include a lack of awareness about how cultural differences affect mentoring and learning for overseas nurses during their period of supervised practice prior to registration with the UK Nursing and Midwifery Council. These barriers may demonstrate a lack of effective teaching of ethical practice in the (...) context of cultural diversity in health care. This argument is supported by empirical data from a national study. Interviews were undertaken with 93 overseas nurses and 24 national and 13 local managers and mentors from six research sites involving UK health care employers in the NHS and independent sectors in different regions of the UK. The data collected showed that overseas nurses are discriminated against in their learning by poor mentoring practices; equally, from these data, it appears that mentors are ill-equipped by existing mentor preparation programmes to mentor overseas-trained nurses from culturally diverse backgrounds. Recommendations are made for improving mentoring programmes to address mentors’ ability to facilitate learning in a culturally diverse workplace and thereby improve overseas nurses’ experiences of their supervised practice. (shrink)

No one who attended the 2010 national public health law conference hosted by the Public Health Law Association and the American Society of Law, Medicine & Ethics could miss the sense of excitement and momentum. The revival of this annual public health law meeting, with the support of the Robert Wood Johnson Foundation, the energetic leadership of the PHLA president and board, ASLME’s expert guidance, and a rousing address by Dr. Tom Frieden, Director of the (...) Centers for Disease Control and Prevention, symbolize the continued commitment of a wide range of important individuals and institutions to the proposition that law is of substantial importance to public health. But there is more than just symbolism to be excited about. CDC’s public health law program continues to champion efforts to promote the use and understanding of law as a public health tool. (shrink)

No one who attended the 2010 national public health law conference hosted by the Public Health Law Association and the American Society of Law, Medicine & Ethics could miss the sense of excitement and momentum. The revival of this annual public health law meeting, with the support of the Robert Wood Johnson Foundation, the energetic leadership of the PHLA president and board, ASLME’s expert guidance, and a rousing address by Dr. Tom Frieden, Director of the (...) Centers for Disease Control and Prevention, symbolize the continued commitment of a wide range of important individuals and institutions to the proposition that law is of substantial importance to public health. But there is more than just symbolism to be excited about. CDC’s public health law program continues to champion efforts to promote the use and understanding of law as a public health tool. (shrink)

Migrant nurses form an increasing proportion of the nursing workforce, with the United Kingdom (UK) being the third most popular destination for overseas nurses in the world. The migrant nurse workforce is highly susceptible to policy changes at the macro or professional level of the donor and recipient countries. Freedom of information requests were issued to 19 National Health Service [NHS] Trusts in England to determine their involvement in overseas nurse recruitment activity from 1998 onwards. These indicate (...) a notable shift away from active European Union (EU) recruitment and towards overseas countries particularly the Philippines and India. Reasons given were as follows: diminishing returns from EU sources, high attrition among EU nurses and the introduction of English language tests for EU nurses in July 2016. This led to Trusts revisiting their recruitment strategies by increasing more direct/less resource‐intensive methods and expanding their focus outside of the EU. Trusts frequently utilised private recruitment companies for their recruitment drives, including consulting and influencing the Trusts’ workforce strategies. Policy adjustments have numerous influences on the composition of the overseas nursing workforce. While the NHS continues its efforts in expanding its international nursing workforce, this should not be at the expense of ethical and sustainable recruitment practices, which may be compromised indirectly as a result. (shrink)

Definition of the problem Death and suicide wishes of older people represent a relevant and morally challenging issue for nurses. Especially in the context of wishes for assisted suicide, the risk for the development of moral uncertainty or even moral distress grows. As suicide rates and requests for assisted suicide are particularly high among people 65 years of age or older, the topic proves to be particularly relevant to the settings of long-term community and nursing home care. At the (...) same time, this fact underlines the importance of suicide prevention, which has recently been strengthened by the federal government, with the intention of launching a national strategy and a corresponding law. Arguments According to our hypothesis, the situational confrontation of nursing professionals with death and suicide wishes may cause an ethical field of tension between an unprejudiced, open, empathetic and respectful acceptance of death and suicide wishes on the one hand and the goal of suicide prevention on the other. The legal uncertainties in regards to the practice of assisted suicide, which currently prevails in practice, may intensify this risk. International studies point to the potential of moral distress of nurses when confronted with death and suicide wishes. Conclusion These findings and the reference to the current legal uncertainties and framework conditions in the national (German) context underpin the importance of the professional discussion about the topic, the need to sensitise (future) nursing professionals to potential ethical tensions and to enable them to deal with the accompanying moral uncertainty in a professional and competent manner. (shrink)

‘Zero tolerance’ of avoidable infection events is explicit in UK and international policy documents describing strategies for the control of healthcare-associated infection. I consider what principles governing avoidable infections acquired in healthcare institutions might be reasonably rejected from the contractualist perspective of Thomas Scanlon. Many hospital infections can be cost-effectively avoided. There would seem to be additional reasons to take the prevention of avoidable infection acquired in hospitals seriously in addition to optimizing the cost-effectiveness of healthcare. These include the irretrievable (...) nature of the harm of some of the infections; the reasonable rejection of avoidable harm when the patient could not rationally consent to the risk of harm and the social consequences such as loss of trust in healthcare providers. Despite these reasons, a principle of ‘zero tolerance’ has implausible implications, promotes unrealistic patient expectations and can be reasonably rejected from the perspective of those who will suffer unacceptable opportunity costs. However, the contractualist perspective would also seem to reject a principle of tolerance of harm when there is a feasible reconfiguration of institutional arrangements that reduces the risk of harm without a redistribution of a proportionate or greater burden to others. (shrink)

HALLETT C and WAGNER L. Nursing Inquiry 2011; 18: 359–368 Promoting the health of Europeans in a rapidly changing world: a historical study of the implementation of World Health Organisation policies by the Nursing and Midwifery Unit, European Regional Office, 1970–2003The World Health Organisation (WHO) was inaugurated in 1948. Formed in a period of post‐war devastation, WHO aimed to develop and meet goals that would rebuild the health of shattered populations. The historical study (...) reported here examined the work of the Nursing and Midwifery Unit (NMU) of WHO’s European Regional Office during the later part of the twentieth century. The study examined archive sources lodged at the NMU archive. The sources included manuscripts relating to important NMU initiatives, reports and papers published by WHO, and a range of secondary sources. The study identified three main driving forces in the work of the NMU of the European Regional Office of WHO. One of the strongest of these was a drive to develop and promote the nursing profession within the countries of the European Region. The second was the promulgation and implementation of the positive public health strategies of WHO, particularly its ‘38 Targets for Health for All by the Year 2000’. The third focussed on securing equity across the European continent and on promoting the development of the nursing professions in poorer and less‐developed countries. The study concludes that the nursing professions in European states grew in strength and influence, and that the health of populations improved throughout the continent between 1970 and 2003. It discusses the extent to which the role of the NMU in these advances may have been significant. (shrink)

INTRODUCTION BY NANCY FUMERO What is a translation that stalls comprehension? That, when read, parsed, obfuscates comprehension through any language – English, Portuguese. It is inevitable that readers expect fidelity from translations. That language mirror with a sort of precision that enables the reader to become of another location, condition, to grasp in English in a similar vein as readers of Portuguese might from João Guimarães Rosa’s GRANDE SERTÃO: VEREDAS. There is the expectation that translations enable mobility. That (...) what was written in one language be accessible in another. And that a translator is to serve as a mediator, acting ultimately in service to ideas within the source text. To disperse them. However, this notion of translation is partly antithetical to the ideas in Rosa’s work. Or, alternately, to convey the despair of terrain slipping beneath one’s feet, and to encounter the heightened suspense of magic, the translation, as part of its strategy, cannot devotedly rely on its original language, not as its source text. The work undertaken by Felipe W.Martinez is a new form of translation that risks everything in order to encounter the same treacherous knowing Rosa had traversed. And it takes its risks by not taking risks: by being, almost word for word, a literal translation. This is an approach that reductively converts, as opposed to translates. The idiomatic differences between English and Portuguese are not accented. The syntax is not finessed. Liberties are not assumed on account of improving readability. What stands, resoundingly amid such absences, is the awakened challenge of reading. The genuine peril of not knowing. That is, this translation, one that purports to know nothing, creates access into the guileful world Rosa had created in Portuguese. But not by translating. If anything, GRANDE SERTÃO: VEREDAS is speaking a cosmic language through a linguistic one. And W.Martinez does us the service of recognizing this, as what configures the shapes of words and sentences is not as simple as neologisms, portmanteaus, and digressions, but as terrifying as the path the fool traverses: all paths. As such, this translation doesn’t speak English, just as the original does not speak Portuguese. It is the assemblage of paradox as a new logic that can be navigated, if only one could suspend the comfort of readability, of expectation. If one could descend a mountain in the pitch dark of night, each step shocking the body, unable to acclimate to the unleveled heights. Without a doubt, the translation is incongruous to the Portuguese. Taking a small excerpt to compare: Eh, well, thereafter, the rest the Sir provide: comes the bread, comes the hand, comes the god, comes the dog. What is striking is the interplay between “god” and “dog”. To most English speakers, this anagram is a familiar one. But in Portuguese the words god (“deus”) and dog (“cão”) are not so closely linked. In fact, there is no direct mention of “deus” in Rosa’s text: Eh, pois, empós, o resto o senhor prove: vem o pão, vem a mão, vem o são, vem o cão. Both are fascinating. In Rosa’s excerpt, the rhythm is unmistakable and precise, despite, of course, the indices of hesitation: the commas, the Eh, the uncomfortable way of searching through prolongation and wait. This is the sort of paradox Rosa can engage within a sentence. W.Martinez’s does this as well, at a scale that reverberates beyond the sentence, and with one noticeable addition: deus. What may appear to be an overstep, to add such a weighted word that draws out wordplay but is, nevertheless, not in the source text, is exemplary of risk. The translation buzzes because of it. This is because throughout the text we encounter dogs frequently, as some primal beast on par with humans. The dog is one that masters and can be mastered. A creature that is at times its face, and at others a mask. It is a powerful presence. For the translator to be attuned to the reverent undercurrent attributed to this animal, and create within the translation such charged play in English from what was only an implication in Portuguese, is in tribute to the grand beauty within dissonance. What aberrant modes of writing and translation can teach us most assuredly, is that things, words, are not in states of rightness or wrongness, but of oscillation. This isn’t so different from what Rosa says himself: The Sir look…see: the most important and beautiful, of the world, is this: that the people are not always same, still were not completed — but that they go always shifting. They tune or detune. We find this so readily in W.Martinez’s translation, this tuning and detuning. Nancy Fumero Los Angeles GRAND SERTÃO: VEREDAS BY JOÃO GUIMARÃES ROSA TRANSLATED FROM THE PORTUGUESE BY FELIPE W.MARTINEZ Nonothing. Shots that the Sir heard were man brawling not, God be. Bleach white sights on the tree in the backyard, down in the river. By my right. I do this every day, I like; from the bad of boyhood. Thereof they came to call on me. Case of a calf: a white calf, errorful, eyes of to not be—saw selves—; and with a mask of a dog! They told me; I didn’t want to catch a sight. Same that, by the defects of birth, upturned lips, looked to be a laughing man. Folkface, dogface: they determined—it was the devil. Bananas. Killed it. Do not know who owned it. They came to borrow my guns. I caved. I’ve no power to impose. Oh, sir, you laugh certain laughs…Look: when it’s a true shot, first the dogs begin to bark, instantly—after, then, you see who’s handed death. Sir, endure, this is the Sertão. Some want that it is not: that situated Sertão is in and out of those general fields, they say, end of the road, highlands, the other Urucuia. Toleima. For those of Cortino and of Curvelo, then, isn’t here said Sertão? Ah! That there’s more! To place the Sertão it’s told: it’s where the pastures lack latches; where one can tear off ten, fifteen leagues without running into a houseinhabitant; where criminalousness lives out its christ jesus. Sifted out from the tightening grip of the law. The Urcuia comes from the western mountains. But today, its banks, give all—farmlands of farms, pastures of meadows of good yield, low tides, cultures that go kill for kill, until these virgins there are. The general fields run round. These general fields are without size. Ultimately, whichever one one approves, the Sir knows: bread or breads, it’s a question of heads…the Sertão is everywhere. Of the devi? No comment. Sir ask the dwellers. Falsely I fear they unspeak that name of his—only say: whatsitcalled. Volt! no… Whosoever over avoids it, lives with it. In the sentence of one Aristides—who exists in the first palm grove on the right hand side, called Vereda-of-Cow-Calm-of-Saint-Rita—everyone believes: he can't pass in three designated places: then can be heard the tiny cry, behind, a little voice warning:— "Here I come! Here I come!... "— that is the Capirote, the whatsitcalled... And one Jise Simplicio—who anyone from here will swear he keeps an imp in house, a little satanite, imprisoned and obliged to help in all greedful deeds; reason that Simplicio emprises en route to complete riches. As such, for this they say too that his beast bristles and refuses, denying his banner, unyielding, when he wishes to mount... Superstition. Jise Simplicio and Aristides, continue getting fatter, thence unheard or heard. Still the Sir study: right now, in these days of time, you have people purporting that the devil proper stopped, mid-passage, in Andrequice. A boy out of there, to whom'd appeared, and there lauded that, to get here—normally, by horse, a day-n-half—he was capable of such with only some twenty minutes enough... by coasting the River of Chico by the headwaters! Or, too, who knows—sans offense—will not have been, for example, even yourself the Sir who announced such, when you passed by there, for fun run funny? Thereof, not my given crime, I know that wasn't. And evil I wanted not. Only that one question, in hours, at times, brightens peaceful reason. But, the Sir understand: if such a boy, there was, he wanted to dupe. Because, hey, that, to cut the river off by the springs, would be the same thing as one redoubling in the internals of this our state of ours, costant of a journey of some three months... Then? Whatsitcalled? Dodo. The fantastication. And, the respect of giving him such these names of delicacy, is what it is for one to want to invoke that he form of form, with his presence! Not that is. I, personally, almost that have lost in him the creed, deserving to Deus; is the that to the Sir I say, to pure-secret. I know that it is well established, that it greases our Saintly-Gospels. On occasion, I conversed with a young seminarian, super suitable, conferring in the book of prayers and coated in vestments, with a stick of black-sage in hand—prosed that he went auxilitator to the father, to extract the Cujo, from the body living of an oldwoman, in Waterfalls-of-Bulls, he went with the vicar of Field-Round... I conceive. The Sir not is as I? I didn't believe a single thing. Compadre mine Quelemem describes that that which reveals effect are the low spirits meager, of third, adoing in the worst darkness and with anxieties of connecting selves with the livers—they give support. Compadre mine Quelemem is who much me consoles—Quelemem of Goias. But he has to live far from here, in Jijuja, Vereda of Buriti Dark... Ahrr, I leave myself there, that in enevildemonment or with support—the Sir too must have had known diverse, men, women. As not yes? For me, umpteen I've seen, that I've learned. Ma-Neigh, Blood-o'Other, or Legion-Lips, or Tear-em-Down, Cold-Cutter, or Sissy-Goat, one Treciziano, or Verdigris... or Hermogenes... o'them, pileload. If I could forget so many names... I'm not a man for calming horses! And, same, whom of yes of to be jagunço self enters, yea is for some competence entrant of demonion. Will it not? Will it? From first, I made and mixed, and to think not I thought. I didn't have the deadlines. I lived pulling difficult from difficult, fish alive on griddle: who lives asp'rously, no fantasies. But, now, fete of fate to me comes, and sans little disquietudes, I'm from creaky net. And myself invented in this like, of to speculate ideas. The devil exists and nonexists? I say the saying. Opennouncement. These melancholies. The Sir sees: exists waterfall; and since? But waterfall is gulch of ground, and water so pouring from it, retumbling; the Sir consume that water, or undo that bankment, remainder waterfall any? To live is negotiation much perilous. I explain to the Sir: the devil vigors inside of human, the wrinkles of human— or is the human ruin, or the human of adversess. I free, per se, citizen, is that not has devil notone. Notone!— is the that I say. The Sir approve? Me declares total, frank— is high merit that me make: and to beg might, increased. This case— by rashtravagance that me they see— is of mine certain importance. God grant not was... But, not say that the Sir, awised and instructed, that agrees in people of them?! Not? You I appreciate! Your high opinion composes my value. Yea I knew, waited for it— yea the field! Ah, a we, in oldness, we lack of to have plowing of rest. You I appreciate. Is devil notone. Nor esprit. Never I've seen. Someone ought to see, then was I myself, this your servant. Was I you to tell... Well, the devil regulate his state black, ins creatures, ins womens, ins humans. E'en: ins childrens— I declaim. Since not is said: "boy—trainee of the devil"? And ins thes uses, ins plants, ins waters, in terra, in wind... Manures. …The devil in the street, in the middle of the vortex... Hey? Hey? Ah. Figuration mine, of worse by back, the certain memories. Mal-make me! I suffer pain of to tell not…Meliorate, if chillingly: well, in a ground and with equal format of branches and leaves, not give to cassava-calm, that is eaten common, and the cassava-mad that kills? Now, the Sir yea saw a strangeness? A cassava-sweet can rapidly to turn agonizing— motives not I know, at times is said that is for replanted in the terrain always, with mutations then, of caules—go embittering, of s’much in s’much, of its self takes poisons. And, well look: the other, the cassava-mad, too is that at times can fix calm, the estimate, of is to eat sans notone mal. And what this is? Eh, the Sir yea saw, for to see, the ugliness of hate pleated, facetorqued, on the faces of one cobrarattlesnake? Observed the porker fat, capita day more felicity brute, capable of, could, snort and engulf for its own dirty coziness the world total? And sparrowhawk, blackbird, some, the features of they yea represent the need of cleave for before, rend and shred by beak, appears a knife much fine for ruin I desire. Total. Has even twisted races of stone, horrorous, venomous— that spoil mortal the aquas, if they are buried beneath of well; the devil inside of them sleeps: they are the devil. Is known? And the demon— that is only thus the significance of one mercury malign— have order of to follow the path of him, have license to brag?! Arr, he is variegated in all! What the what wastes, goes spending the devil of inside of the people, by itttybits, is the reasonable to suffer. And the delight of love—compadre mine Quelemem says. Family. Really? Is, and not is. The Sir think and not think. Total is and not is… Almost all more grave criminous ferocity, always is much good husband, good son, good father, and is good-friend-of-your-friends! I know of those. Solo that have the afters— and Deus, joined. I spy many nimbi. But, in veracity, son, too, softens. Look: one called Aleixo, resident a league from Step-of-Sour, in Of-Sand, was the man of major badness calm that yea you saw. Me agreed that near the house of his had a weir, amidst the palms, with traíras, for souls of enormous, desenormous, to the real, that received fame; the Aleixo gave of to eat to them, in hours just, they self accustomed to if assuch of lunacies, in order to gobble, seemed to be fishes instructed. One day, solo for grace rustic, he killed an oldman who by there passed, destitute begging alms. The Sir not doubt—have people, in this bored world, that kill solo in order to see someone make grimace… Eh, well, thereafter, the rest the Sir provide: comes the bread, comes the hand, comes the god, comes the dog. This Aleixo was man afamilied, had children small; they were the love of his, total, absurdity. Gave good, that not even a year there passed, of to killed the oldman poor, and the children of Aleixo there they asickened. Smallepidemic of measles, they said, but complex; they never heal. When, then, they healed. But the eyes of theirs vermillionized high in an inflame of spraining to rebellion; and nexthing— the that not I know is if they went of at once, or one later and later other and other— they remained blind. Blind, sans remission of one sweet of light of this Ours! The Sir imagine: stairset— three boys and one girl— all blind. Sans remediable. The Aleixo not lost the judgment, but he changed; ah, mutated complete— now lives of band of Deus, sweating to be good and charitous in all his hours of night and of day. Appears even that he fixed the felicity, that before not was. He himself says he was a man of luck, because Deus wanted to have pity of him, to transform for there the route of his soul. That I heard, and me it gave rage. Reason of the children. If being castigated, what culpa of the let-there-bes of Aleixo those little children had?! Compadre mine Quelemem reproved my uncertainties. That, for certain, inother life returnaound, the children too had been the most wicked, of the mass and part of the father, demons of the same kettle of place. Sir the what thinks? And the oldman, assassinated? — I know the Sir goes to discuss. Well, too. In order that he had a sin of crime, in the body, by to pay. If the people— conforming compadre mine Quelemem is who says— if the people turn to to incarnate renovated, I contemplate even that enemy of death can come as son of the enemy. Look see: if to myself I say, has a subject Pedro Pindo, neighbor of here more six leagues, man of good for all in all, he and the woman of his, always been good, of goodness. They have a son of some ten years called Valtei—name modern, is the that the population of here now appreciates, the Sir knows. Well this-little-thing, thislet, since that some understanding illuminated in him, deed demonstrated the that is: petition stepfather, acid burner, likeful of ruin of inside of the profundity of the species of its nature. In which that torments, to the slowly, of all beasts or raisinglings little that quarrel; one time he found a creole woman hooched foolish sleeping, he arranged a shard of bottle, lashed at three points on the stern of the legs of hers. The what this boy drooled seeing, is bleeding hen or to knife pig.— “I enjoy of to kill…”— one occasion he teeny me told. He opened in me a fright; because: birdy that self leans over— the flight yea is ready! Well the Sir oversee: the pa, Pedro Pindo, mode of to correct this, and the ma, they give in him, misery and mast—they cast the boy sans to eat, they tied to trees in the yard, he nude, unplumed, even in June cold, they tilled the bittybody of his with the trammel and with the goblet, after they cleansed the skin of the sanguine, with bottle gourd brine. The people know, spy, fix wasted. The boy yea relowered of thinness, the eyes entering, caress of bones, enskulled, and tuberculated, the time total hacking, coughness of the that draw parched pectorals. Arr, that now, visible, the Pindo and the woman self habituated of on him hit, of little bit in little they were creating in this a pleasure ugly of diversion— as they regulate the canings in hours certain comfortable, until they call people to see the example good. I think that boy not endure, yea there is in the ta-da, not arrive for the lent to come… Ooee-ooee, then?! Not being as compadre mine Quelemem to want, that explication is that the Sir bestowed? That boy had to be a man. He should, in swing, terrible perversities. Soul of his was in the pitch. Demonstrated. And, now, paid. Ah, but, happens, when he’s crying and paining, he suffers equal that as was as a boy good… Bird, I saw all, in this world! Yea I saw even horse with hiccups… —the that the thing most costous that is. Good, but the Sir may say, should of: and in the start— for offenses and arts, the people— as for that was that s’much amended was started? Ey, ey, ey all collided. Compadre mine Quelemem, too. Am solo a sertanite, in these high ideas I navigate mal. Am much poor poor-thing. Envy my pedigree and of ones conform the Sir, with total reading and doctoration. Not is that I be illiterate. I spelt, years and middle, midly speller, memory and palmer. I had master, Master Lucas, in the Curralinho, he memorized grammar, the operations, rule-of-three, even geography and study patria. On leaves great of paper, with caprice I traced handsome maps. Ah, not is for to speak: but, since of the start, me they thought sophisticated of side. And that I merited of to go to course latin, in Lesson Waterlily—that too they said. Time nostalgic! Going today, I appreciate a good book, despaced. On the farm The Lilittlelemon, of one mine friend Vito Soziano, so sign of this almanac thick, of logoglyphs and conundrums and other divided matters, all year come. In s’much, I place primacy is in the reading advantageous, life of saints, virtues and examples— missionary astute engambling the Indians, or Saint Francis of Assis, Saint Anthony, Saint Gerald… I like much of moral. To ratiocinate, exhort the others for the good way, to acounsel to just. Mine woman, that the Sir knows, vigils for me: much prayer. She is a blessable. Compadre mine Quelemem always says that I may to aquiet my fears on conscience, that being well-attended, terrible good-esprits me protect. Eep! With like… As is of saint effect, I help with mine to want to accredit. But not even always can I. The Sir knew: I total the mine life I thought for me, lining, I am born different. I am and I same. I divert of total the world… I almost that nothing not I know. But I disconfide of many things. The Sir, conceding, I say: in order to think long, I am dog master— the Sir loose in mine front an idea ease and I research that by profundity of total the backwoods, amen! Look: the should of to have, was of so reunited-selves the wise, politicos, constitutions graded, closed the definitive the notion— to proclaim for one time, art assemblies, that not have devil notone, not exists, not possible. Valor of law! Solo assuch, they gave tranquility good to the people. Because the government not cares?! Ah, I know that not is possible. Not me settled the Sir for philistine. One this is to place ideas arranged, other is to deal with country of people, of flesh and sanguine, of thousand-and-many miseries… S’many people—gives scare of to know—and notone so calms: All nascenting, crescendoing, so wedding, wanting collocation of employment, consumables, health, abundance, to be important, wanting rain and affairs good… Of luck that lacks of so to choose: or we t’weave of to live in the salacious common, or care solo of religion solo. I could to be: father clergyman, if not chief of jagunços; for other things not was I birthed. But mine oldness yea principaled I erred of total account. And the rheumatism… There as whom says: in the primers. Ahem. Hey? Hey? The that more I think, I testify and explain: all-the-world is mad. The Sir, I, we, the people all. For this is that so lacks principally of religion: in order to desendodorize, to disdodoate. Pray is that heals of lunacy. In the general. This is that is the salvation-of-the-soul…Much religion your servant! I here, not I lose occasion of religion. I profit of all. I drink water of all rivers… One solo, for me is little, maybe not me arrives. I pray christian, catholic, I burrow the certain; and I accept the prayers of compadre mine Quelemem, doctrine of he, of Kardec. But, when I can, I go in the Mindubim, where one Matias is believer, methodist: the people so accuse of sinner, reads high the bible, and why, singing hymns beautiful of his. Total me quiets, me suspends. Whatever small shade me refreshes. But is solo much provisory. I wanted to pray— the time total. Many people not me approve, they think that law of Deus is privileges, invariable. And I! Doof! I Detest! The what I am? — the what I do, that want, much curia. And in face of total I face, executed. I? —not I trammel. Look: I have a black girl, Maria Leoncia, long from here not she lives, the prayers of her afame much virtue of power. Well to her I pay, every month— ordering of to pray for me one third, every saint day, and, on the Sundays, a rosary. Value, so values. Mine woman not sees mal in this. And I am, yea mandated word for an other, of the voyage-voyage, a Izina Calanga, in order to come here, I heard of that prayer too with grand mermermerits, I go to effect with she treatment equal. I want handful of those, me defending in Deus, reunited of me in volta… Cuts of Christ! To live is much perilous… To want the good with too much force, of incertain way, can yea to be being so wanting the mal, per to initiate. These humans! All they pull the world for itself, for the to concert amended. But capita one solo sees and understands the things of one his world. Amountain, the most supro, most serious was Mediero Vaz. That one man ancient… his Joaozy Ben-Ben, the most brave of all, no-one never can decipher how he by inside consisted. Joca Ramiro— grand man prince!— was politico. Zé Bebelo wanted to be politico, but had and not had luck: fox that lingered. So Candelario so demonized, by to think that was with illness mal. Titao Passos was the by the appreciation of friends: solo per via of them, of his same amities, were that such high so ajagunçoed. Antonio Do— severe bandit. But by half, grand majority half that be. Andalecio, in the profound, a good man-of-good, being raving in his total justice. Ricardao, same, wanted was to be rich in peace: for this he warred. Solo the Hermogenes was that born formed tiger, and assassinite. And the “Ofidios White”? Ah, not me speak. Ah this… joyless mischeivious, that was— that was a poor boy of the destiny… So good, congruous. The Sir heard, I you told: the ruin with the ruin, they terminate by the spine-bushes so to crack— Deus awaits that spendance. Boy!: Deus is patience. The contrary, is the devil. So consumes. The Sir file knife on knife— and file— that so they scrape. Even the rocks of the profound, one of in the other, they go-so aroundabounding even, that the rivulet rolls. Per enquantity, that I think, total as hath, in this world, is because so merits and lacks. Afterly precise. Deus not so reports with rifle, not garrotes the regulation. For what? Quit: goof with goof—one day, some illumination and learn: smart. Solo that, at times, for most auxiliar, Deus begets, in the middle, a pinch of pepper… Therebe? Well, for example: some time, I went of train, there in Seven-Lagoons, for parts of to consult a medical, of name me indicated. He went vested well, and in car of first, by via of the doubts, not me they shadowed for jagunço ancient. It goes and happens, that, close same of me, enfront, he took aseat, returning from the wild North, a mac Jazevedao, delegate professionale. Came with a capanga of his, an undercover, and I well knew the two, of that s’much a was ruin, as the other ruin was. The veracity to say, first I had the strict of me to surpasss for one lonng, to mutate of my place. Judgement me told, meliorate stay. Well, looking, I looked. And— you I tell: never I saw face of man furnished of brutez or malady more, of the them in that. As that was ogre, trussed of thickset, relustered of crude in the eyes small, and armed a chin of stone, toweringbrow; not of mid nor forehead. Not laughed, not so laughed not even one time; but, speaking or silent, the people appeared always to him some teeth, prey pointed of canids. Arr, and blustered, an ittybit. Solo growled curt, low, the mid-words grizzled. He came relooking, historicizing the documents— one by one the leaves with portraits and with the blacks of the digits of jagunços, lifters of horses and criminouses of death. That application of work, in one thing of those, generated the ire in the people. The undercover, busybodyguard, total close, seated joined, attending, excelling of to be dog. Me made a dread, but solo in the goof of the corpus, not in the intern of the courages. One hour, one of those reports fell— and I bent quickly, I knew there precisely by why, not I wanted, not I thought— even today I raise shame of this— I picked the paper of the ground, and delivered to him. Thereof, I say: I had more rage, because I did that; but there yea it was done. The man not even me looked, not even said notone thankfulment. Event he soles of the shoes of his— solo looking— that soles rough thick, bent of enormous, appearing iron bronzed. Because I knew: This Jazevedao, when he apprehended someone, the primary quiet thing that proceeded was that he came entering, sans to have to to say, feigning some hurry, and go stepping on the top of the feet of the poorthings. And that on these occasions he gave laughters, gave… Well, geck! I delivered to him the leaf of paper, and went leaving of there, by to have hand on me of not to destroy by shots that subject. Meat that much they weigh… And umbilicated beginning of belly pot bellied, that me created will… With my lightness, joyful that I’d kill. But, the barbarities that this delegate made and happened, the Sir not even has callus in heart to be able me to hear. He achieved of many men and women to cry blood, for the simple universolo ours here. Sertão. The Sir knows: sertão is where mandates who is strong, with the guile. And bullet is a tidbit of metal… S’much, I say: Jazevedao— one assuch, should of to have, needed? Ah, need. Leather ruined is that calls goad of point. That there be that, after— business particular of he— in the life or in the other, each Jazevedao, accomplished the that he has, desclimbs in his time of pain, too, until to pay the that he gave— compadre mine Quelemem is there, in order to fiscalize. The Sir knows: the peril that is to live… But solo of the mode, of these, by ugly instrument, was that the jagunsaga so finished. Sir thinks that Antonio Do or Olivino Oliviano were going to fix goodies by pure spelling of itself, or by begging of the infelicitous, or by always to hear sermon of father? You I think! In the aims… Of jagunço comported active in order so to repent in the middle of his jagunsagas, solo I lay of one: called Joe Cazuzo— was in smashing of one shotshow, for on the summit of the place Sierra New, district of river rusted, on the stream Traçadal. We made mal minority small, and they closed in order summit of us the personnel of one Coronel Adalvino, forted politico, with many soldiers uniformed in the center, commanding of the Lieutenant Epiphany Helm, that after fixed captain. We lasted hour more hour, and yea gave almost of encircled. There, of misslip, that Joe Cazuzo— man much valiant— so kneeled turned on the ground of the thick, lifted the arms that not even shoots of Jatoba dry, and solo yell, howl clear and howl deaf:— “I saw the Virgin Ours, in the resplendor of the Heavens, with her children of angels!... ” He screamed not touched. — “I saw the Virgin!... ” He ensouled? We desequaled. Bolt for my horse—that I thought— I leaped in mal seat, noteven I knew in which rupture-time I unfastened the halter, of tied up it foot of timber. I flew, arrived. Bullet come. The pasture roared. In the brush, the fear of the people so goes to the whole, one fear intentional. I could to lash out, fated burro brute, giv-that, giv-that. Some two or three bullets so drovein the pad of the mine saddle, they perforated of to tear away almost much the kapok of the filling. Horse trembled in pro, in middle of gallop, I know: thinks in the owner. I not fit of to be more well shrunken. Bulleted came to the sack that I had on the back, with few mine things. And other, of fusil, in ricochet decreed, heated my thigh, sans me wound, the Sir see: bullet does the what to want—so pierced impressed, between in me and the harness! Times crazy… Burumbum!: the horse so kneeled in the fall, dead perhaps, and I yea falling for front, embraced in foliage full, branched and linias, that me swayed and skewered, done I was pendulating in web of spider… Whither? I traversed that life total… Of fear of anxiety, I ruptured to read with mine corpus that forest, I know there — and me fell world below, rolled for the hollow of a grotto closed of shrubs, always me grasped— rolled same assuch: after: after, when I saw mine hands, total on they that not was withdrawn sanguine, was smeared green, on the digits, of leaves living that I pulled and mashed… I landed on the sedge of the profound— and a beast dark gave a releap, with a sneeze, too mad of fright: that was a papa-mel, that I descried; in order to flee, this is solely. Bigger being I, me doused mine overcoat; I spigotted total. And of one bit of thought: if that beast irara lying there then there not had cobra. I took the place of his. Existed cobra notone. I could me to lose. I was solo spineless, softness, but that not deadened, inside, the collisions of the heart. I gasped. I conceived that they came, me kill. Not even did mal, me mattered not. Assuch, some moments, at least I guarded the license of term in order me to rest. Conforming I thought in Diadorim. Solo I thought was in he. One joão-congo sang. I wanted to die thinking in my friend Diadorim, hand-o-bro, who was on the Sierra of WoodO’Bow, almost on the border baiana, with our other half of the so-candelarios… With my friend Diadorim me embraced, sentiment my went-flew right for he… Ay, arr, but: that this mine mouth not has order notone. I am accounting outside, things divagated. In the Sir me confide? Til-that, til-that. Say the angel-of-the-guard… But, conforming I came: after so knew, that same the soldiers of the Lieutenant and the goats of Coronel Adalvino remitted of to respect the blast of that Joe Cazuzo. And that this ended being the man most pacificious of the world, fabricator of oil and sacristan, in the Saint Sundays White. Times! For total, cleaned revelation, I fix thinking. I like. Meliorate, for the idea if well to open, is travelling in train-of-iron. Could, lived to top and to bottom, inside of it. Information that I ask: same in the Heavens, end of end, how is that the soul wins so to forget s’much sufferments and maladies, in the received and in the given? The how? The Sir knows: are things of hideous ofmuch, have. Pain of corpus and pain of idea mark forted, that forted as the total love and rage of hate. Goes, sea… Of luck that, then, the Firmiano, by appellationed Louse-of-Snake, so leoprosized with the leg disconformed, thickening, of that disease that not so cures; and not discern almost more, constant the branchials in the eyes, of the cataracts. Of before, years, had to of so disarray of the jagunsaga. Well, one occasion, some was on the ranch of his, on the High Jeuitai, after accounted—that, turns time, comes subject, he would say: “Me give yearning is of to seize a soldier, and such, for one good flay, with knife blind… But, first, to castrate…” The Sir conceive? Who has more dose of demon in self is Indian, any race of brusque. Folk see nation ofthese, for there profound of the generals of Goias, theofwhere has vagarous grand rivers, of aquas always so clear pleasantly, running of down crystal rosed… Louse-of-Snake gave of sanguine of heathen. Sir me will say: but that he pronounced that out of mouth, manner of to represent that yet not was old decadent. Opus of to oppose, for fear of to be tame, and cause in order so to see respected. Total listened for such rule: palavered of ruins, for more so valued, because we to the environs is hard durability. The worst, but, is that they finish, through the same ford, given of one day to execute the declared, in the real. I saw s’much crudity! Pain not pays to account; if I go, I collide. And me dedrip, three that me sicken, this total. Me convokes that the personnel, today in day, is good of heart. This is, good in the trivial. Malices wildwants, and perversities, always have some, but scarcities. Generation mine, true, was not assuch. Ah, goes to turn a time, in which not is used more to kill people… I yea am old. Good, I was saying: question, this that me excavates… Ah, I formed that question, for compadre mine Quelemem. That me responded: that, for close to heaven, we so amplified so, that total the uglies past so exhaled of not to be—fated sans-modus from time of youngster, mal-arts. As we not lack of to have remorse of the which divulged in the pulsation of his nightmares of one night. Assuch that: fleeced-so, flourished-so! Ahem. For this said, is that the journey to the Heavens is delayed. I confide with compadre mine Quelemem, the Sir knows: reason of creed same that has—that, for total the mal, that so does, one day so repays, the exact. Subject assuch rises three times, in ante of to want to facilitate in any minutia reprehensible… Compadre mine Quelemem never speaks vacant, not subtreats. Solo that this to he not I go to expose. We never should have to declare that accept entire the alien—that is what is the rule of the king! The Sir look…see: the most important and beautiful, of the world, is this: that the people are not always same, still were not completed — but that they go always shifting. They tune or detune. Truth major. Is the that the life me taught. This that me animates, mound. And, other thing: the devil and the brutes; but Deus is treacherous! Ah, a beauty of treacherous— gives like! The force of his, when he wants— boy!— me gives the fear dread! Deus comes coming: no one not sees. He does in the law of gentle— assuch is the miracle. And Deus attacks beautiful, so amusing, so economizes. The well: one day in a tannery, the little knife mine I had dropped inside of a tank, solo soup of bark of tan, stryphnodendron adstringens, angico, there I know. —“Tomorrow I try…”— I said, withmyself. Because it was of night, light notone I not disputed. Ah, then, I found: on the other day, early, the knife, the iron of it, had been gnawed, almost by half, by that aqua dark, total quiet. I left, for more to see. Crack, fuse! Know the what was? Well, in that same of afternoon, there: of the little knife solo so found the handle… The handle, for not to be of cold metal, but of horn of deer. There is: Deus… Good, the Sir heard knows, the that knows me understands… We sum, not think that religion fractures. Sir think the contrary. Visible that, those other times, I painted—belief that the neoglaziovia variegata lifts the flower. Ah, good my joy… Boyhood. But boyhood is task for more later so to deny. Too, I of that of to think in vague in s’much, lost mine hand-of-man for the management hot, in the middle of all. But, today, that I ratiocinated, and think the endeavor, not nor for this not I give for low my competence, in a fire-and-iron. The to see. Would approach would come here with war on me, with bad parts, with other laws, or with excessive looks, and I even draw to ignite this zone, ay, if, if! Is in the mouth of the blunderbuss: is in the rete-te-tem… And lonelyonly not I am, there-of-the. For not this, I was I placed encircle my mine people. Look the Sir: here, close, vereda below, the Paspe — cropper my — is mine. More league, if that, have the Herpetotheres, and have the compadre Ciril, him and three children, I know that they serve. Band of that hand, the Alaripe: knew the Sir the that is that so boasts, in rifleation and by the knife, one cearense did this! After more: the João Innatal, the Quipes, Lophiosilurus-of-claws. And the Fafafa— this gave fights high, all side with me, in the combat old of the Anteater-such: we cleaned the wind of whom not had order of to respirate, and ante these we desencompassed… The Fafafa has a mass of mares. He raises horses good. Even a little more distant, on the ped-of-sierra, of band mine was the Sesfred, Jesualdo, the Nelson, and João Concliz. Some others. The Triol… And not I go valuing? I leave terra with them, of theirs the what is mine is, we close that we not even brothers. For what I want to gather richness? They are there, of arms aireated. Enemy to come, we cross called, gathering: is hour of one good shotshowerment in peace, they exp’riment to see. I say this to the Sir, of confidence. Too, not go to think in double. We want is to work, propose tranquility. Of me, person, I live for mine woman, that total mode-meliorate merits, and for the devotion. Well-to want of mine woman was that me assisted, prayers of hers, graces. Love comes of love. I say. In Diadorim, I think too— but Diadorim is the mine nebulina… Now, well: not I wanted to touch on this more— of the Tineaous; arrive. But has a nevertheless: I ask: the Sir believe, think trust of truth in that parlance, of with the demon so to able to deal with pact? No, no is no? I knew that not there. I spoke of favas. But I like of total good confirmation. To vend you proper soul… Inventionate false! And, soul, the what is? Soul of has to be thing internal supremed, much more of the of inside, and is solo, of the that one if thought: ah, soul sheer! Decision of to vend soul is fearless moll, fantasied of moment, has not the obedience legal. Can I to vend those good terras, thereof of between the Veredas-Four— that are of one Mr. Admiral, who resides in the capital federal? Can I some? Then, if one boy boy is, and for this not so authorizes of to negotiate… And we, this I know, at times is solo fated boy. Mal that in mine life I prepared, I was in a certain infancy in dreams — total runs and arrives so swift —; will be that if hath flame of responsibilities? If dream; yea so did… I gave rapadura to the chump! Ahem. Well. If his soul, and has, it is of Deus established, not even that the person want or not want. Not is vendible. The Sir not thinks? Me declare, frank, I beg. Ah, you I appreciate. You so see that the Sir knows much, in idea firm, beyond of to have letter of doctor. You I appreciate, for much. Your company me gives high pleasures. In terms, I liked that I would live here, or close, was a help. Here not so has conviviation that to instruct. Sertão. Knows the Sir: sertão is where the thought of the people so forms more forted of the than power of the place. To live is much perilous… Eh, that you so go? Yeayea? Is that not. Today, no. Tomorrow, no. Not I consense. The Sir me forgive, but in endeavor of mine friendship accept: the Sir stay. After fifth of-morning-early, the Sir wanting to go, then goes, same me leaves feeling your absence. But, today or tomorrow, no. Visit, here in house, with me, is for three days! But, the Sir really intends to trespass the field this sea of territotires, for sortment of to confer the what exists? You have your motives. Now— I say for me — the Sir comes, came late, Times were, the customs mutate. Almost that, of legitimate loyal, little surplus, not even no excess more nothing. The bands good of valientoughs they reparted their end; many who were jagunço, by ouch pain, beg alms. Same as the herdsmen they doubt of to come in the commerce vested of clothes entire of leather, they think that garb of jerkin is ugly and boor. And even the herd in the shrubbed pasture goes waning less mad, more educated: casted of zebu, dissee with the rest of corralers and captiveborns. Always, in the generals is to the poverty, to the sadness. A sadness that even gladdens. But, then, for a crop reasonable of bizzarancies, I recounsel of the Sir to entest journey more dilated. Not were my desmight, by acids and rheumatism, there I went. I guided the Sir till total. March 2013 San Diego, CA ORIGINAL TEXT NONADA. TIROS QUE O SENHOR ouviu foram de briga de homem não, Deus esteja. Alvejei mira em árvores no quintal, no baixo do córrego. Por meu acerto. Todo dia isso faço, gosto; desde mal em minha mocidade. Daí, vieram me chamar. Causa dumbezerro: um bezerro branco, erroso, os olhos de nem ser – se viu –; e com máscara de cachorro. Me disseram; eu não quis avistar. Mesmo que, por defeito como nasceu, arrebitado de beiços, esse figurava rindo feito pessoa. Cara de gente, cara de cão: determinaram – era o demo. Povo prascóvio. Mataram. Dono dele nem sei quem for. Vieram emprestar minhas armas, cedi. Não tenho abusões. O senhor ri certas risadas... Olhe: quando é tiro de verdade, primeiro a cachorrada pega a latir, instantaneamente – depois, então, se vai ver se deu mortos. O senhor tolere, isto é o sertão. Uns querem que não seja: que situado sertão é por os campos-gerais a fora a dentro, eles dizem, fim de rumo, terras altas, demais do Urucuia. Toleima. Para os de Corinto e do Curvelo, então, o aqui não é dito sertão? Ah, que tem maior! Lugar sertão se divulga: é onde os pastos carecem de fechos; onde um pode torar dez, quinze léguas, sem topar com casa de morador; e onde criminoso vive seu cristo-jesus, arredado do arrocho de autoridade. O Urucuia vem dos montões oestes. Mas, hoje, que na beira dele, tudo dá – fazendões de fazendas, almargem de vargens de bom render, as vazantes; culturas que vão de mata em mata, madeiras de grossura, até ainda virgens dessas lá há. O gerais corre em volta. Esses gerais são sem tamanho. Enfim, cada um o que quer aprova, o senhor sabe: pão ou pães, é questão de opiniães... O sertão está em toda a parte. Do demo? Não gloso. Senhor pergunte aos moradores. Em falso receio, desfalam no nome dele – dizem só: o Que-Diga. Vote! não... Quem muito se evita, se convive. Sentença num Aristides – o que existe no buritizal primeiro desta minha mão direita, chamado a Vereda-da-Vaca-Mansa-deSanta-Rita – todo o mundo crê: ele não pode passar em três lugares, designados: porque então a gente escuta um chorinho, atrás, e uma vozinha que avisando: – “Eu já vou! Eu já vou!...” – que é o capiroto, o que-diga... E um José Simpilício – quem qualquer daqui jura ele tem um capeta em casa, miúdo satanazim, preso obrigado a ajudar em toda ganância que executa; razão que o Simpilício se empresa em vias de completar de rico. Apre, por isso dizem também que a besta pra ele rupeia, nega de banda, não deixando, quando ele quer amontar... Superstição. José Simpilício e Aristides, mesmo estão se engordando, de assim nãoouvir ou ouvir. Ainda o senhor estude: agora mesmo, nestes dias de época, tem gente porfalando que o Diabo próprio parou, de passagem, no Andrequicé. Um Moço de fora, teria aparecido, e lá se louvou que, para aqui vir – normal, a cavalo, dum dia-e-meio – ele era capaz que só com uns vinte minutos bastava... porque costeava o Rio do Chico pelas cabeceiras! Ou, também, quem sabe – sem ofensas – não terá sido, por um exemplo, até mesmo o senhor quem se anunciou assim, quando passou por lá, por prazido divertimento engraçado? Há-de, não me dê crime, sei que não foi. E mal eu não quis. Só que uma pergunta, em hora, às vezes, clareia razão de paz. Mas, o senhor entenda: o tal moço, se há, quis mangar. Pois, hem, que, despontar o Rio pelas nascentes, será a mesma coisa que um se redobrar nos internos deste nosso Estado nosso, custante viagem de uns três meses... Então? Que-Diga? Doideira. A fantasiação. E, o respeito de dar a ele assim esses nomes de rebuço, é que é mesmo um querer invocar que ele forme forma, com as presenças! Não seja. Eu, pessoalmente, quase que já perdi nele a crença, mercês a Deus; é o que ao senhor lhe digo, à puridade. Sei que é bem estabelecido, que grassa nos Santos- Evangelhos. Em ocasião, conversei com um rapaz seminarista, muito condizente, conferindo no livro de rezas e revestido de paramenta, com uma vara de maria-preta na mão – proseou que ia adjutorar o padre, para extraírem o Cujo, do corpo vivo de uma velha, na Cachoeira-dos-Bois, ele ia com o vigário do Campo-Redondo... Me concebo. O senhor não é como eu? Não acreditei patavim. Compadre meu Quelemém descreve que o que revela efeito são os baixos espíritos descarnados, de terceira, fuzuando nas piores trevas e com ânsias de se travarem com os viventes – dão encosto. Compadre meu Quelemém é quem muito me consola – Quelemém de Góis. Mas ele tem de morar longe daqui, na Jijujã, Vereda do Buriti Pardo... Arres, me deixe lá, que – em endemoninhamento ou com encosto – o senhor mesmo deverá de ter conhecido diversos, homens, mulheres. Pois não sim? Por mim, tantos vi, que aprendi. Rincha- Mãe, Sangued’Outro, o Muitos-Beiços, o Rasgaem-Baixo, Faca-Fria, o Fancho-Bode, um Treciziano, o Azinhavre... o Hermógenes... Deles, punhadão. Se eu pudesse esquecer tantos nomes... Não sou amansador de cavalos! E, mesmo, quem de si de ser jagunço se entrete, já é por alguma competência entrante do demônio. Será não? Será? De primeiro, eu fazia e mexia, e pensar não pensava. Não possuía os prazos. Vivi puxando difícil de dificel, peixe vivo no moquém: quem mói no asp’ro, não fantaseia. Mas, agora, feita a folga que me vem, e sem pequenos dessossegos, estou de range rede. E me inventei neste gosto, de especular idéia. O diabo existe e não existe? Dou o dito. Abrenúncio. Essas melancolias. O senhor vê: existe cachoeira; e pois? Mas cachoeira é barranco de chão, e água se caindo por ele, retombando; o senhor consome essa água, ou desfaz o barranco, sobra cachoeira alguma? Viver é negócio muito perigoso... Explico ao senhor: o diabo vige dentro do homem, os crespos do homem – ou é o homem arruinado, ou o homem dos avessos. Solto, por si, cidadão, é que não tem diabo nenhum. Nenhum! – é o que digo. O senhor aprova? Me declare tudo, franco – é alta mercê que me faz: e pedir posso, encarecido. Este caso – por estúrdio que me vejam – é de minha certa importância. Tomara não fosse... Mas, não diga que o senhor, assisado e instruído, que acredita na pessoa dele?! Não? Lhe agradeço! Sua alta opinião compõe minha valia. Já sabia, esperava por ela-já o campo! Ah, a gente, na velhice, carece de ter sua aragem de descanso. Lhe agradeço. Tem diabo nenhum. Nem espírito. Nunca vi. Alguém devia de ver, então era eu mesmo, este vosso servidor. Fosse lhe contar... Bem, o diabo regula seu estado preto, nas criaturas, nas mulheres, nos homens. Até: nas crianças – eu digo. Pois não é ditado: “menino – trem do diabo”? E nos usos, nas plantas, nas águas, na terra, no vento... Estrumes. ... O diabo na rua, no meio do redemunho... Hem? Hem? Ah. Figuração minha, de pior pra trás, as certas lembranças. Mal hajame! Sofro pena de contar não... Melhor, se arrepare: pois, num chão, e com igual formato de ramos e folhas, não dá a mandioca mansa, que se come comum, e a mandioca-brava, que mata? Agora, o senhor já viu uma estranhez? A mandioca-doce pode de repente virar azangada – motivos não sei; às vezes se diz que é por replantada no terreno sempre, com mudas seguidas, de manaíbas – vai em amargando, de tanto em tanto, de si mesma toma peçonhas. E, ora veja: a outra, a mandiocabrava, também é que às vezes pode ficar mansa, a esmo, de se comer sem nenhum mal. E que isso é? Eh, o senhor já viu, por ver, a feiúra de ódio franzido, carantonho, nas faces duma cobra cascavel? Observou o porco gordo, cada dia mais feliz bruto, capaz de, pudesse, roncar e engolir por sua suja comodidade o mundo todo? E gavião, corvo, alguns, as feições deles já representam a precisão de talhar para adiante, rasgar e estraçalhar a bico, parece uma quicé muito afiada por ruim desejo. Tudo. Tem até tortas raças de pedras, horrorosas, venenosas – que estragam mortal a água, se estão jazendo em fundo de poço; o diabo dentro delas dorme: são o demo. Se sabe? E o demo – que é só assim o significado dum azougue maligno – tem ordem de seguir o caminho dele, tem licença para campear?! Arre, ele está misturado em tudo. Que o que gasta, vai gastando o diabo de dentro da gente, aos pouquinhos, é o razoável sofrer. E a alegria de amor – compadre meu Quelemém, diz. Família. Deveras? É, e não é. O senhor ache e não ache. Tudo é e não é... Quase todo mais grave criminoso feroz, sempre é muito bom marido, bom filho, bom pai, e é bom amigo-de-seus-amigos! Sei desses. Só que tem os depois – e Deus, junto. Vi muitas nuvens. Mas, em verdade, filho, também, abranda. Olhe: um chamado Aleixo, residente a légua do Passo do Pubo, no da-Areia, era o homem de maiores ruindades calmas que já se viu. Me agradou que perto da casa dele tinha um açudinho, entre as palmeiras, com traíras, pra-almas de enormes, desenormes, ao real, que receberam fama; o Aleixo dava de comer a elas, em horas justas, elas se acostumaram a se assim das locas, para papar, semelhavam ser peixes ensinados. Um dia, só por graça rústica, ele matou um velhinho que por lá passou, desvalido rogando esmola. O senhor não duvide – tem gente, neste aborrecido mundo, que matam só para ver alguém fazer careta... Eh, pois, empós, o resto o senhor prove: vem o pão, vem a mão, vem o são, vem o cão. Esse Aleixo era homem afamilhado, tinha filhos pequenos; aqueles eram o amor dele, todo, despropósito. Dê bem, que não nem um ano estava passado, de se matar o velhinho pobre, e os meninos do Aleixo aí adoeceram. Andaço de sarampão, se disse, mas complicado; eles nunca saravam. Quando, então, sararam. Mas os olhos deles vermelhavam altos, numa inflama de sapiranga à rebelde; e susseguinte – o que não sei é se foram todos duma vez, ou um logo e logo outro e outro – eles restaram cegos. Cegos, sem remissão dum favinho de luz dessa nossa! O senhor imagine: uma escadinha – três meninos e uma menina – todos cegados. Sem remediável. O Aleixo não perdeu o juizo; mas mudou: ah, demudou completo – agora vive da banda de Deus, suando para ser bom e caridoso em todas suas horas da noite e do dia. Parece até que ficou o feliz, que antes não era. Ele mesmo diz que foi um homem de sorte, porque Deus quis ter pena dele, transformar para lá o rumo de sua alma. Isso eu ouvi, e me deu raiva. Razão das crianças. Se sendo castigo, que culpa das hajas do Aleixo aqueles meninozinhos tinham?! Compadre meu Quelemém reprovou minhas incertezas. Que, por certo, noutra vida revirada, os meninos também tinham sido os mais malvados, da massa e peça do pai, demônios do mesmo caldeirão de lugar. Senhor o que acha? E o velhinho assassinado? – eu sei que o senhor vai discutir. Pois, também. Em ordem que ele tinha um pecado de crime, no corpo, por pagar. Se a gente – conforme compadre meu Quelemém é quem diz – se a gente torna a encarnar renovado, eu cismo até que inimigo de morte pode vir como filho do inimigo. Mire veja: se me digo, tem um sujeito Pedro Pindó, vizinho daqui mais seis léguas, homem de bem por tudo em tudo, ele e a mulher dele, sempre sidos bons, de bem. Eles têm um filho duns dez anos, chamado Valtei – nome moderno, é o que o povo daqui agora apreceia, o senhor sabe. Pois essezinho, essezim, desde que algum entendimento alumiou nele, feito mostrou o que é: pedido madrasto, azedo queimador, gostoso de ruim de dentro do fundo das espécies de sua natureza. Em qual que judia, ao devagar, de todo bicho ou criaçãozinha pequena que pega; uma vez, encontrou uma crioula bentabêbada dormindo, arranjou um caco de garrafa, lanhou em três pontos a popa da perna dela. O que esse menino babeja vendo, é sangrarem galinha ou esfaquear porco. – “Eu gosto de matar...” – uma ocasião ele pequenino me disse. Abriu em mim um susto; porque: passarinho que se debruça – o vôo já está pronto! Pois, o senhor vigie: o pai, Pedro Pindó, modo de corrigir isso, e a mãe, dão nele, de miséria e mastro – botam o menino sem comer, amarram em árvores no terreiro, ele nu nuelo, mesmo em junho frio, lavram o corpinho dele na peia e na taca, depois limpam a pele do sangue, com cuia de salmoura. A gente sabe, espia, fica gasturado. O menino já rebaixou de magreza, os olhos entrando, carinha de ossos, encaveirada, e entisicou, o tempo todo tosse, tossura da que puxa secos peitos. Arre, que agora, visível, o Pindó e a mulher se habituaram de nele bater, de pouquinho em pouquim foram criando nisso um prazer feio de diversão – como regulam as sovas em horas certas confortáveis, até chamam gente para ver o exemplo bom. Acho que esse menino não dura, já está no blimbilim, não chega para a quaresma que vem... Uê-uê, então?!Não sendo como compadre meu Quelemém quer, que explicação é que o senhor dava? Aquele menino tinha sido homem. Devia, em balanço, terríveis perversidades. Alma dele estava no breu. Mostrava. E, agora, pagava. Ah, mas, acontece, quando está chorando e penando, ele sofre igual que se fosse um menino bonzinho... Ave, vi de tudo, neste mundo! lá vi até cavalo com soluço... – o que é a coisa mais custosa que há. Bem, mas o senhor dirá, deve de: e no começo – para pecados e artes, as pessoas – como por que foi que tanto emendado se começou? Ei, ei, aí todos esbarram. Compadre meu Quelemém, também. Sou só um sertanejo, nessas altas idéias navego mal. Sou muito pobre coitado. Inveja minha pura é de uns conforme o senhor, com toda leitura e suma doutoração. Não é que eu esteja analfabeto. Soletrei, anos e meio, meante cartilha, memória e palmatória. Tive mestre, Mestre Lucas, no Curralinho, decorei gramática, as operações, regra-de-três, até geografia e estudo pátrio. Em folhas grandes de papel, com capricho tracei bonitos mapas. Ah, não é por falar: mas, desde o começo, me achavam sofismado de ladino. E que eu merecia de ir para cursar latim, em Aula Régia – que também diziam. Tempo saudoso! Inda hoje, apreceio um bom livro, despaçado. Na fazenda O Limãozinho, de um meu amigo Vito Soziano, se assina desse almanaque grosso, de logogrifos e charadas e outras divididas matérias, todo ano vem. Em tanto, ponho primazia é na leitura proveitosa, vida de santo, virtudes e exemplos – missionário esperto engambelando os índios, ou São Francisco de Assis, Santo Antônio, São Geraldo... Eu gosto muito de moral. Raciocinar, exortar os outros para o bom caminho, aconselhar a justo. Minha mulher, que o senhor sabe, zela por mim: muito reza. Ela é uma abençoável. Compadre meu Quelemém sempre diz que eu posso aquietar meu temer de consciência, que sendo bem-assistido, terríveis bons-espíritos me protegem. Ipe! Com gosto... Como é de são efeito, ajudo com meu querer acreditar. Mas nem sempre posso. O senhor saiba: eu toda a minha vida pensei por mim, forro, sou nascido diferente. Eu sou é eu mesmo. Diverjo de todo o mundo... Eu quase que nada não sei. Mas desconfio de muita coisa. O senhor concedendo, eu digo: para pensar longe, sou cão mestre – o senhor solte em minha frente uma idéia ligeira, e eu rastreio essa por fundo de todos os matos, amém! Olhe: o que devia de haver, era de se reunirem-se os sábios, políticos, constituições gradas, fecharem o definitivo a noção – proclamar por uma vez, artes assembléias, que não tem diabo nenhum, não existe, não pode. Valor de lei! Só assim, davam tranqüilidade boa à gente. Por que o Governo não cuida?! Ah, eu sei que não é possível. Não me assente o senhor por beócio. Uma coisa é pôr idéias arranjadas, outra é lidar com país de pessoas, de carne e sangue, de mil-e-tantas misérias... Tanta gente – dá susto de saber – e nenhum se sossega: todos nascendo, crescendo, se casando, querendo colocação de emprego, comida, saúde, riqueza, ser importante, querendo chuva e negócios bons... De sorte que carece de se escolher: ou a gente se tece de viver no safado comum, ou cuida só de religião só. Eu podia ser: padre sacerdote, se não chefe de jagunços; para outras coisas não fui parido. Mas minha velhice já principiou, errei de toda conta. E o reumatismo... Lá como quem diz: nas escorvas. Ahã. Hem? Hem? O que mais penso, testo e explico: todo-omundo é louco. O senhor, eu, nós, as pessoas todas. Por isso é que se carece principalmente de religião: para se desendoidecer, desdoidar. Reza é que sara da loucura. No geral. Isso é que é a salvaçãoda- alma... Muita religião, seu moço! Eu cá, não perco ocasião de religião. Aproveito de todas. Bebo água de todo rio... Uma só, para mim é pouca, talvez não me chegue. Rezo cristão, católico, embrenho a certo; e aceito as preces de compadre meu Quelemém, doutrina dele, de Cardéque. Mas, quando posso, vou no Mindubim, onde um Matias é crente, metodista: a gente se acusa de pecador, lê alto a Bíblia, e ora, cantando hinos belos deles. Tudo me quieta, me suspende. Qualquer sombrinha me refresca. Mas é só muito provisório. Eu queria rezar – o tempo todo. Muita gente não me aprova, acham que lei de Deus é privilégios, invariável. E eu! Bofe! Detesto! O que sou? – o que faço, que quero, muito curial. E em cara de todos faço, executado. Eu não tresmalho! Olhe: tem uma preta, Maria Leôncia, longe daqui não mora, as rezas dela afamam muita virtude de poder. Pois a ela pago, todo mês – encomenda de rezar por mim um terço, todo santo dia, e, nos domingos, um rosário. Vale, se vale. Minha mulher não vê mal nisso. E estou, já mandei recado para uma outra, do Vau-Vau, uma Izina Calanga, para vir aqui, ouvi de que reza também com grandes meremerências, vou efetuar com ela trato igual. Quero punhado dessas, me defendendo em Deus, reunidas de mim em volta... Chagas de Cristo! Viver é muito perigoso... Querer o bem com demais força, de incerto jeito, pode já estar sendo se querendo o mal, por principiar. Esses homens! Todos puxavam o mundo para si, para o concertar consertado. Mas cada um só vê e entende as coisas dum seu modo. Montante, o mais supro, mais sério – foi Medeiro Vaz. Que um homem antigo... Seu Joãozinho Bem-Bem, o mais bravo de todos, ninguém nunca pôde decifrar como ele por dentro consistia. Joca Ramiro – grande homem príncipe! – era político. Zé- Bebelo quis ser político. (shrink)

Indigenous nurse scholars across nations colonised by Europeans articulate the need for accomplices (as opposed to mere performative allies) to work alongside them and support their ongoing struggle for health equity and respect and to prioritise and promote culturally safe healthcare. Although cultural safety is now being mandated in nursing codes of practice as a strategy to address racism in healthcare, it is important that white nurse educators have a comprehensive understanding about cultural safety and the pedagogical skills (...) needed to teach it to undergraduate nurses. We open this article with stories of our journeys as two white nurses in becoming accomplices and working alongside Indigenous Peoples, as patients and colleagues. Our lived experience of the inertia of healthcare and education organisations to address systemic and institutional resistance to the practice of cultural safety underpins the intention of this article. We understand that delivering this challenging and complex topic effectively and respectfully is best achieved when Indigenous and white educators work together at the cultural interface. Doing so requires commitment from white nurses and power holders within universities and healthcare institutions. A decolonising approach to nurse education at individual and institutional levels is fundamental to support and grow the work that needs to be done to reduce health inequity and increase cultural safety. White nurse accomplices can play an important role in teaching future nurses the importance of critical reflection and aiming to reduce power imbalances and racism within healthcare environments. Reducing power imbalances in healthcare environments and decolonising nursing practice is the strength of a cultural safety framework. (shrink)

This article presents empirical data on the limited availability of hospice and palliative care to the 6 million people of the English-speaking Caribbean. Ten of the 13 nations therein responded to a survey and reported employing a total of 6 hospice or palliative specialists, and having a total of 15 related facilities. The evolving socioeconomic and cultural context in these nations bears on the availability of such care, and on the willingness to report, assess, and prioritize pain, and to (...) prescribe opiates for pain. Socioeconomics and culture also impinge on what medications and modalities of care are routinely available for pain or other conditions and can challenge professionalism, empathy, and responsiveness to patients’ unrelieved pain. Although all respondents report having a protocol for pain management, hospice, or end-of-life care, their annual medical use of opiates is well below the global mean. The International Narcotics Control Board , which monitors such use, encourages Caribbean and other low- and middle-income countries to increase their use of opiates to treat pain, and to overcome both unfounded fears of addiction and overly restrictive interpretation of related laws and regulations. Contextual considerations like those described here are important to the success of policies and capacity-building programs aiming to increase access to hospice and palliation, and perhaps to improving other aspects of health and healthcare. Exploring and responding to the realities of socioeconomic and cultural conditions will enhance public and policy dialogue and improve the design of interventions to increase access to palliative and hospice care. Improving access to palliative and hospice care in the Caribbean demonstrates beneficence and helps to fulfill human rights conventions. (shrink)

The following text explores performative art works commissioned within a specific “arts and health” cultural setting, namely that of a medical school within a British university. It examines the degree to which the professional autonomy of the artists was “instrumentalized” and diminished as a result of having to fit into normative frames set by institutional agendas. We ask to what extent do such “entanglements,” feel more like “enstranglements,” suffocating the artist’s capacity to envision the world afresh or any differently? (...) What kinds of pressures allow for certain kinds of “evidence” to be read and made visible,? Are You Feeling Better? was a 2016 programme curated by Frances Williams, challenging simplistic expectations that the arts hold any automatic power of their own to make “things better” in healthcare. It included two performative projects – The Secret Society of Imperfect Nurses, by Anthony Schrag with student nurses at Kings College London, and Hiding in Plain Sight by Becky Shaw with doctoral researchers in nursing and midwifery. These projects were situated in a climate of United Kingdom National Health Service cuts and austerity measures where the advancement of social prescribing looks dangerously like the government abnegating responsibility and offering art as amelioration. The text therefore examines the critical “stage” on which these arts-health projects were performed and the extent to which critical reflection is welcomed within institutional contexts, how learning is framed, expressed aesthetically, as well as understood as art practice. It further examines how artistic projects might offer sites of resistance, rejection and mechanisms of support against constricting institutional norms and practices that seek to instrumentalise artistic works to their own ends. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Clinical Bioethics at NIH:History and A New VisionJohn C. Fletcher (bio)On July 3, 1995, Dr. John I. Gallin, Director of the Magnuson Clinical Center of the National Institutes of Health (NIH), convened a one-day "Conference on the Future of Clinical Bioethics at the National Institutes of Health Intramural Program." Conferees included NIH officials and a panel of consultants from bioethics programs around the nation.1 The (...) subject was the future of NIH's intramural bioethics program and specifically a vision of a new multi-component program, presented by Dr. Gallin, the first speaker. Dr. Harold Varmus, Director of NIH, was there to assure his support for Dr. Gallin's vision. This author, honored to be second speaker, was invited to sketch a brief history of bioethics at NIH. The present article reviews some of this history and then reports on Dr. Gallin's proposal, points of consensus among speakers and conferees, and the search for a Chief of the Clinical Bioethics Program.History of Bioethics at NIHIt is often said that NIH is a well-kept secret as the nation's leading biomedical research facility. Also, few people know that NIH has a long history in bioethics. Some key events in that history are shown in Figure 1, beginning with two that occurred prior to the birth of bioethics. NIH made an early policy response to protect human subjects of research and to find acceptable limits for scientific freedom. The Clinical Center (CC), a 550-bed research hospital, opened in 1953. A subcommittee of the Medical Board, the Clinical Research Committee (CRC), was formed for prior group review of all studies with normal volunteers. The traditional practice was for researchers themselves to decide when studies would begin, which subjects to recruit, and whether informed consent would be sought. The CRC intervention bit into this tradition. In addition, patient studies that posed significant risks or departed widely from medical practice were reviewed by referral from the Clinical Directors of the various Institutes. Was this CRC an early institutional review [End Page 355] board (IRB)? As a guest researcher, I was permitted to observe the CRCs meetings between 1966 and 1969. It functioned much like an IRB but had no community or non-scientist members. Other IRB-like review groups undoubtedly existed prior to the CRC. Robert Levine (personal communication, September 7, 1995) recalls that Beth Israel Hospital in Boston had one in 1938. Historical research is clearly needed on the earliest forms of research review.Table 1. Bioethics at NIHEventYearClinical Research Committee1953Surgeon-General's PPO #1291966NIGMS funds Hastings Genetics Group1973OPRR's Mission1974NLM's grant to KennedyInstitute for Bibliography of Bioethics1974Recombinant DNA Advisory Committee1974STEP Series Bioethics Speakers1975Pre-IRBs at the CC1975-76Assistant for Bioethics to Director, CC1977RAC-Human Gene Therapy Subcommittee1983Lipsett Proposal (ICD)1983Liaison Group, CC1983Bioethics Program, CC1985Durable Power of Attorney for Researchwith Incapacitated Subjects1985-86NLM funds National Reference Centerfor Bioethics Literature1985National Institute for Nursing Research1986Bioethics Post-Doctoral Fellows Program1989ELSI Program1989Bioethicists on CC-IRBs1989CC-Ethics Committee1990Office of Human Subjects Research1992 [End Page 356]Between 1963 and 1967, the media exposed instances of ethically troubling research, and Beecher (1966) and Pappworth (1967) published sharp criticisms of the weak state of research ethics. In 1966, Surgeon-General William Stewart and NIH Director James Shannon issued a policy requiring local group review of all research involving human subjects before making an application for NIH peer review (Surgeon General 1966). The policy was the first in any nation to mandate ethics committees for clinical research. However, it did not apply to the NIH intramural program until Congress passed the National Research Act in 1974 (Public Law 93-348; 202, 88 Stat. 342, 1974). This lag permitted NIH intramural investigators the luxury of feeling above the norms imposed on ordinary mortals and guaranteed more resistance to the inevitable change to come. Resistance to change marked the intramural program from the mid-1960s to the mid-1970s... (shrink)

In lieu of an abstract, here is a brief excerpt of the content:The Veterans Affairs National Center for Clinical EthicsJames L. Bernat (bio)The veterans health administration is the largest health care system in the United States and, indeed, is larger that the health care system of many foreign countries. In February 1991 the Department of Veterans Affairs (V.A.) in Washington, D.C. awarded a contract to the clinical ethics group at the Veterans Affairs Medical Center in White (...) River Junction, Vermont to establish the V.A. National Center for Clinical Ethics. In this article I describe the organizational context, mission, operation, and future direction of the Center, which William A. Nelson, Ph.D., and I co-direct.The Veterans Health AdministrationThe Department of Veterans Affairs operates 171 hospitals providing services ranging from primary, secondary, and tertiary medical care to psychiatric hospitals, rehabilitation centers, and nursing homes. The V.A. also provides outpatient services at all hospitals and at dozens of free-standing outpatent clinics. V.A. medical centers employ over 14,000 physicians and serve approximately 4.5 million veteran patients (Hollingsworth and Bondy 1990; Mirvis 1990).The V.A. serves an important educational function, providing training sites for medical students, postgraduate physicians, and trainees in other health-related fields. Approximately 78 percent of V.A. medical centers are affiliated with medical schools. Over one-third of all American medical students and over 40 percent of interns and residents spend a portion of their training in V.A. medical centers. More than 100,000 students in all health-related fields train in V.A. facilities annually (Hollingsworth and Bondy 1990).Research is another mission of the V.A. Many academic physicians and scientists derive their research and salary funding from V.A contracts and awards. The V.A. Research Career Development Program provides the means for many medical school faculty members to achieve successful careers as scientists and clinical investigators. Although research accounts for only slightly more than 1 percent of the V.A. medical budget, two V.A. researchers have been awarded the Nobel Prize (Hollingsworth and Bondy 1990). [End Page 385]In comparison to other medical care settings, the average V.A. patient is likely to be older, poorer, male, less well-educated, more chronically ill, and more expensive to care for. Many patients first patronize the V.A. system after they have been bankrupted by the costs of a major illness. Unlike young, healthy patients ideally favored by health maintenance organizations, these patients immediately require large expenditures for hospitalizations, medications, and other treatments. Additional burdens have been placed on V.A. facilities by a record of chronic federal underfunding over the past decade, despite expanded patient censuses at every facility.Bioethical issues arise in V.A. facilities with great frequency for several reasons. Older and poorer patients are often sicker, have fewer home-support resources, and have completed fewer advance directives for health care. Chronic operational underfunding requires explicit health care rationing systemwide. Academic physicians within the V.A. system have multiple professional duties that have the potential for conflict. Although their primary duty is to their patients, they also must serve the federal government and their medical school academic supervisors. The practice of medical care rationing pits the physician's professional duty to his patient against his duty to the system (Mirvis 1990).The V.A. has responded to these bioethical demands with several initiatives. Hospital ethics advisory committees have been developed in nearly every V.A. medical center. The V.A. National Bioethics Committee has been empaneled to encourage uniform policies across the V.A. system concerning bioethical issues. Most recently, funds were provided for the V.A. National Center for Clinical Ethics.Functions of the National Center for Clinical Ethics (NCCE)The NCCE has a fourfold mission: 1) to enhance the quality of clinical ethics programs at all 171 V.A. medical centers nationwide; 2) to staff the V.A. National Bioethics Committee; 3) to assist administrators and planners in the V.A. Central Office on policy development concerning bioethical issues; and 4) to study, organize, and coordinate clinical, educational, and research bioethics programs throughout the system.Enhancing the quality of clinical ethics programs at V.A. medical centers is largely an... (shrink)

Background Increase in global health research undertaken in resource poor settings in the last decade though a positive development has raised ethical concerns relating to potential for exploitation. Some of the suggested strategies to address these concerns include calls for providing universal standards of care, reasonable availability of proven interventions and more recently, promoting the overall social value of research especially in clinical research. Promoting the social value of research has been closely associated with providing fair benefits to various (...) stakeholders involved in research. The debate over what constitutes fair benefits; whether those that addresses micro level issues of justice or those focusing on the key determinants of health at the macro level has continued. This debate has however not benefited from empirical work on what stakeholders consider fair benefits. This study explores practical experiences of stakeholders involved in global health research in Kenya, over what benefits are fair within a developing world context. Methods and results We conducted in-depth interviews with key informants drawn from within the broader health research system in Kenya including researchers from the mainstream health research institutions, networks and universities, teaching hospitals, policy makers, institutional review boards, civil society organisations and community representative groups. The range of benefits articulated by stakeholders addresses both micro and macro level concerns for justice by for instance, seeking to engage with interests of those facilitating research, and the broader systemic issues that make resource poor settings vulnerable to exploitation. We interpret these views to suggest a need for global health research to engage with current crises that face people in these settings as well as the broader systemic issues that produce them. Conclusion Global health research should provide benefits that address both the micro and macro level issues of justice in order to forestall exploitation. Embracing the two is however challenging in terms of how the various competing interests/needs should be balanced ethically, especially in the absence of structures to guide the process. This challenge should point to the need for greater dialogue to facilitate value clarification among stakeholders. (shrink)

Since 2001, the Commission of the European Union has instigated Peer Reviews to help countries preparing to accede to the European Union. Added to this has been the provision of workshops and individual expert inputs. This article recounts the experiences of the author in this process. It focuses on how a single directive has revealed major ethical challenges for nurses, their national associations and state governments as they seek to implement the changes required. In particular a sub-agenda has emerged (...) relating to general education, access to higher education and the position of women in these countries. The ethical challenges include freedom to practice and creation of competent authorities to provide proper oversight of the health care professions. In 2011, the directive is being reviewed and this article offers arguments for its continuation, even in an unreformed state. (shrink)

BackgroundPromoting the social value of global health research undertaken in resource poor settings has become a key concern in global research ethics. The consideration for benefit sharing, which concerns the elucidation of what if anything, is owed to participants, their communities and host nations that take part in such research, and the obligations of researchers involved, is one of the main strategies used for promoting social value of research. In the last decade however, there has been intense debate within (...) academic bioethics literature seeking to define the benefits, the beneficiaries, and the scope of obligations for providing these benefits. Although this debate may be indicative of willingness at the international level to engage with the responsibilities of researchers involved in global health research, it remains unclear which forms of benefits or beneficiaries should be considered. International and local research ethics guidelines are reviewed here to delineate the guidance they provide.MethodsWe reviewed documents selected from the international compilation of research ethics guidelines by the Office for Human Research Protections under the US Department of Health and Human Services.ResultsAccess to interventions being researched, the provision of unavailable health care, capacity building for individuals and institutions, support to health care systems and access to medical and public health interventions proven effective, are the commonly recommended forms of benefits. The beneficiaries are volunteers, disease or illness affected communities and the population in general. Interestingly however, there is a divide between "global opinion" and the views of particular countries within resource poor settings as made explicit by differences in emphasis regarding the potential benefits and the beneficiaries.ConclusionAlthough in theory benefit sharing is widely accepted as one of the means for promoting the social value of international collaborative health research, there is less agreement amongst major guidelines on the specific responsibilities of researchers over what is ethical in promoting the social value of research. Lack of consensus might have practical implications for efforts aimed at enhancing the social value of global health research undertaken in resource poor settings. Further developments in global research ethics require more reflection, paying attention to the practical realities of implementing the ethical principles in real world context. (shrink)

This original article outlines a theoretical path and posterior critical analysis regarding two relevant matters in modern nursing: patterns of knowing in nursing and commodification contexts in contemporary health systems. The aim of our manuscript is to examine the development of basic and contextual nursing knowledge in commodified contexts. For this purpose, we outline a discussion and reflexive dialogue based on a literature search and our clinical experience. To lay the foundation for an informed discussion, we (...) conducted a literature search and selected relevant articles in English, Spanish, and Portuguese that included contents on patterns of knowing, commodification, and nursing published from 1978 to 2017. Globalization, commodification, and austerity measures seem to have negative effects on nursing. Work conditions are worsening, deteriorating nurse–patient relationships, and limiting reflection on practice. Nurses must develop knowledge to challenge and participate in institutional organization and public health policies. Development of nursing knowledge may be difficult to achieve in commodified environments. Consequently, therapeutic care relationships, healthcare services, and nurses' own health are compromised. However, by obtaining organizational, sociopolitical, and emancipatory knowledge, nurses can use strategies to adapt to or resist commodified contexts while constructing basic knowledge. (shrink)

There is an urgent call for nurses to address climate change, especially in advocating for those most under threat to the impacts. Social justice is important to nurses in their relations with individuals and populations, including actions to address climate justice. The purpose of this article is to present a Global Nurse Agenda for Climate Justice to spark dialog, provide direction, and to promote nursing action for just‐relations and responsibility for planetary health. Grounding ourselves within the Mi'kmaw concept (...) of Etuaptmumk (two‐eyed seeing), we suggest that climate justice is both call and response, moving nurses from silence to Ksaltultinej (love as action). We review the movement for climate justice in nursing, weaving between our own stories, our relations with Mi'kmaw ways of knowing, and the stories of the movement, with considerations for the (w)holistic perspectives foundational to nursing's metaparadigm of person, environment, and health. We provide a background to the work of the Global Nurse Agenda for Climate Justice steering committee including their role at the 26th United Nations Climate Change Conference in Glasgow, 2021, and share our own stories of action to frame this agenda. We accept our Responsibility for the challenges of climate justice with humility and invite others to join us. (shrink)

Death and dying are natural phenomena embedded within complex political, cultural and social systems. Nurses often practice at the forefront of this process and have a fundamental role in caring for both patients and those close to them during the process of dying and following death. While nursing has a rich tradition in advancing the palliative and end‐of‐life care movement, new modes of care for patients with serious and irremediable medical conditions arise when assisted death is legalized in a (...) particular jurisdiction. In early 2015, the Supreme Court of Canada released its landmark decision Carter v. Canada (Attorney General) (‘Carter’), which legalized physician‐assisted suicide in particular clinical situations. The new law provided the broad national framework for Medical Assistance in Dying (MAiD) in Canada but, once the law was passed, provincial and territorial governments and health professional regulatory bodies each had to undertake a process of developing policies, procedures and processes to guide MAiD‐related practice specific to their jurisdiction. In this paper, we begin to examine the political ramifications and professional tensions arising from MAiD for nurses and nursing, focusing specifically upon the impacts for registered nurses. We identify how variations in the provincial and territorial literature and regulatory guidelines across Canada have given rise to role confusion and uncertainty among some registered nurses and how this may potentially impact patient care. We then continue to highlight the need for greater political activism among nurses to foster greater clarity in nursing roles in MAiD and to advocate for improved supports for patients and those close to them. (shrink)

In late 2005, the General Medical Council carried out several consultations. In the review of procedures for sick doctors were proposals to strengthen powers to monitor doctors and plans to introduce unannounced drug testing of doctors whose behaviour raised concerns.1 The GMC consultation on the strategic options for undergraduate medical education considered how education is changing in the light of social and clinical demands. It focused, in part, on developing guidance on medical students’ health and conduct and a proposed (...) national registration system for medical students.2 The most significant consultation in terms of medical ethics was the GMC’s review of Good Medical Practice – its main ethical guidance for doctors.3 The GMC’s aim was to re-define practical and attainable modern standards. A proposed draft emphasised partnership in the doctor-patient relationship, human rights, and doctors’ obligations and responsibilities towards children—all of which are issues increasingly significant in medicine. The consultation also opened up discussion on how far the GMC should be concerned about doctors’ behaviour in their private lives. Should it be concerned, for example, about clinically successful consultants being obsessed with hardcore pornography or having affairs with very young women?4 Questions were also posed about how far doctors can exercise a conscientious objection. Should they be able to refuse to refer pregnant women for abortions because they themselves consider it wrong?5 Other potentially contentious issues questioned the extent to which doctors have rights to protect themselves against risks from patients. British Medical Association policy, dating from the era when HIV first began to be diagnosed, stated that it is unethical to withhold treatment solely because a patient’s condition poses risks to doctors’ health. At the time it was adopted, this policy was intended to be anti-discriminatory as HIV patients were already stigmatised. Doctors …. (shrink)

There is growing international debate about the so-called “right to health” and the likely content of such a right as it is gradually defined by international bodies such as the UN committee on economic, social, and cultural rights. Although some countries, such as Mexico, have incorporated the right of access to basic treatment into their national constitution, practical implications generally remain to be fully articulated. Lawyers have been trying to do this by developing internationally accepted indicators which can (...) be used to measure a nation's progress towards compliance with social, economic and cultural rights.1 Clearly, compliance can only be judged against the yardstick of resources. Restructuring of health services and the need to contain spiralling health costs have led many countries to focus on developing a basic health care package as a “right”. The USA, in the Clinton era, had inconclusive discussions about this and basic packages have been implemented by governments as diverse as Brazil, Germany, Israel, and the Netherlands. As the BMA has discussed,2 the prime responsibility for ensuring that rights are fulfilled rests with governments who are signatory to international human rights declarations. Nevertheless, hospitals and other health facilities may logically be deemed to have some obligations, by delegation from government, to respect the rights of people needing urgent treatment. The question of what this right means to health professionals needs exploring. Access to health care, particularly in a life-threatening emergency, appears to be a fundamental component of any such postulated right. Also, individual health professionals are generally perceived as having an ethical duty to respond to “need” when they are able to help. In July 2001, the potential legal consequences of failing to do so were highlighted by a case in India where the medical administrator of a Delhi hospital refused emergency treatment to …. (shrink)

Successfully navigating the norms of a society is a complex task that involves recognizing diverse kinds of rules as well as the relative weight attached to them. In the United States, different kinds of rules—federal statutes and regulations, scientific norms, and professional ideals—guide the work of researchers. Penalties for violating these different kinds of rules and norms can range from the displeasure of peers to criminal sanctions. We proposed that it would be more difficult for researchers working in the U.S. (...) who were born in other nations to distinguish the seriousness of violating rules across diverse domains. We administered a new measure, the evaluating rules in science task, to National Institutes of Health-funded investigators. The ERST assessed perceptions of the seriousness of violating research regulations, norms, and ideals, and allowed us to calculate the degree to which researchers distinguished between the seriousness of each rule category. The ERST also assessed researchers’ predictions of the seriousness that research integrity officers would assign to the rules. We compared researchers’ predictions to the seriousness ratings of 112 RIOs working at U.S. research-intensive universities. U.S.-born researchers were significantly better at distinguishing between the seriousness of violating federal research regulations and violating ideals of science, and they were more accurate in their predictions of the views of RIOs. Acculturation to the U.S. moderated the effects of nationality on accuracy. We discuss the implications of these findings in terms of future research and education. (shrink)

BackgroundThe concept of benefit sharing to enhance the social value of global health research in resource poor settings is now a key strategy for addressing moral issues of relevance to individuals, communities and host countries in resource poor settings when they participate in international collaborative health research.The influence of benefit sharing framework on the conduct of collaborative health research is for instance evidenced by the number of publications and research ethics guidelines that require prior engagement between stakeholders (...) to determine the social value of research to the host communities. While such efforts as the production of international guidance on how to promote the social value of research through such strategies as benefit sharing have been made, the extent to which these ideas and guidelines have been absorbed by those engaged in global health research especially in resource poor settings remains unclear. We examine this awareness among stakeholders involved in health related research in Kenya.MethodsWe conducted in-depth interviews with key informants drawn from within the broader health research system in Kenya including researchers from the mainstream health research institutions, networks and universities, teaching hospitals, policy makers, institutional review boards, civil society organisations and community representative groups.ResultsOur study suggests that although people have a sense of justice and the moral aspects of research, this was not articulated in terms used in the literature and the guidelines on the ethics of global health research.ConclusionThis study demonstrates that while in theory several efforts can be made to address the moral issues of concern to research participants and their communities in resource poor settings, quick fixes such as benefit sharing are not going to be straightforward. We suggest a need to pay closer attention to the processes through which ethical principles are enacted in practice and distil lessons on how best to involve individuals and communities in promoting ethical conduct of global health research in resource poor settings. (shrink)

Background:Nurses exposed to community health nursing commonly encounter situations that can be morally distressing. However, most research on moral distress has focused on acute care settings and very little research has explored moral distress in a community health nursing setting especially among nursing students.Aim:To explore the moral distress experiences encountered by undergraduate baccalaureate nursing students in community health nursing.Research design:A descriptive qualitative design was employed to explore the community health nursing (...) experiences of the nursing students that led them to have moral distress.Participants and research context:The study included 14 senior nursing students who had their course in Community Health Nursing in their sophomore year and stayed in the partner communities in their junior year for 6 and 3 weeks during their senior year.Ethical considerations:Institutional review board approval was sought prior to the conduct of the study. Self-determination was assured and anonymity and confidentiality were guaranteed to all participants.Findings:Nursing students are vulnerable and likely to experience moral distress when faced with ethical dilemmas. They encounter numerous situations which make them question their own values and ideals and those of that around them. Findings of the study surfaced three central themes which included moral distress emanating from the unprofessional behavior of some healthcare workers, the resulting sense of powerlessness, and the differing values and mindsets of the people they serve in the community.Conclusion:This study provides educators a glimpse of the morally distressing situations that often occurs in the community setting. It suggests the importance of raising awareness and understanding of these situations to assist nursing students to prepare themselves to the “real world,” where the ideals they have will be constantly challenged and tested. (shrink)

Background Encounters of moral distress have long-term consequences on healthcare workers’ physical and mental health, leading to job dissatisfaction, reduced patient care, and high levels of burnout, exhaustion, and intentions to quit. Yet, research on approaches to ameliorate moral distress across the health workforce is limited. Research Objective The aim of our study was to qualitatively explore multi-professional perspectives of healthcare social workers, chaplains, and patient liaisons on ways to reduce moral distress and heighten well-being at a southern (...) U.S. academic medical center. Participants & Research Context Purposive sampling and chain-referral methods assisted with recruitment through hospital listservs, staff meetings, and newsletters. Interested participants contacted the principal investigator and all interviews were conducted in-person. Consent was attained prior to interviews. All interviews were recorded and transcribed verbatim. Research Design Directed content analysis was used to deductively organize codes and to develop themes in conjunction with the National Academy of Medicine’s National Plan for Health Workforce Well-Being. Rigor was attained through peer-debriefing, data triangulation methods, and frequent research team meetings. Ethical Considerations Ethics approval was obtained from the university and medical center institutional review boards. Findings Themes demonstrate that rather than offering interventions in the aftermath of moral distress, multilevel daily practices ought to be considered that pre-emptively identify and reduce morally distressing encounters through (1) the care team, (2) management and leadership, and (3) the health care industry. Strategies include interdisciplinary decision-making, trusting managerial relationships, and organizational policies and practices that explicitly invest in mental health promotion and diverse leadership opportunities. Conclusion Moral distress interventions ought to target short-term stress reactions while also addressing the long-term impacts of moral residue. Health systems must financially commit to an ethical workplace culture that explicitly values mental health and well-being. (shrink)

Health, ethics and COP27 On the 20 November 2022, the United Nations Climate Change COP27 announced a breakthrough agreement to provide ‘loss and damage’ funding for resource-poor countries seriously affected by climate change. 1 The establishment of the funding stream acknowledges, and attempts to address, one of many thorny ethical issues driven by climate change – to what extent countries that have benefited economically from past emissions of greenhouse gases owe reparative obligations to countries who have contributed minimally to (...) climate change but are most at risk of its harms? One of the many reasons why this is such an important breakthrough is that it brings into the centre of climate policy-making questions of global – and intergenerational – justice and fairness. It acknowledges the critical importance of ethics in climate change deliberations. It is probably fair to say that climate change policy has been dominated to... (shrink)

Background Speaking up to safeguard patients is a crucial ethical and moral obligation for nurses, but it is also a difficult and potentially dangerous component of nursing work. Health advocacy is gaining impetus in the medical literature, despite being hampered by barriers resulting in many nurses in Ghana remaining mute when faced with advocacy-required situations. We explored situations that thwart nurses from performing their health advocacy role. Research question What would cause nurses to take no action when (...) they witness situations that require them to act as health advocates for their clients or communities? Research Design An inductive, descriptive qualitative design was used to collect and analyse data on barriers that prevent nurses from practising their health advocacy role in Ghana. Individual one-on-one in-depth interviews were conducted using a semi-structured interview guide. The data were analysed using qualitative content analysis. Participants and research context Twenty-four professional nurses and midwives registered with the Nursing and Midwifery Council were recruited from three regional hospitals in Ghana. These public hospitals were chosen from the upper, middle and coastal regions. Ethical considerations The UKZN Ethics Review Committee in South Africa and the GHS Ethics Review Committee in Ghana both gave their approval for this study. Findings Intrapersonal barriers, interpersonal barriers, and structural barriers emerged as major obstacles that nurses experience when performing their health advocacy role. Conclusions Barriers to health advocacy have undermined nurses' ability to function as health advocates and are preventing them from utilising their health advocacy position in nursing practise. Giving nursing students positive role models in the classroom and in the clinic can help them become more effective health advocates. (shrink)

The British Medical Association and Royal College of Physicians have published new guidance, endorsed by the General Medical Council, on decision-making about clinically assisted nutrition and hydration and adults who lack capacity to consent. The development of the guidance follows a series of legal cases which has created confusion about the precise circumstances in which an application to the court is required before CANH is withdrawn which has culminated with the decision of the Supreme Court in National Health (...) Service Trust versus Y. 1 This confirmed that there is no requirement to go to court, providing there is agreement as to the patient’s best interests, the provisions of the Mental Capacity Act 2005 have been observed, and the relevant professional guidance has been followed. The new guidance covers all decisions to start, restart, continue, or stop providing CANH in patients who are not imminently dying, in circumstances where CANH is the primary life-sustaining treatment being provided. It goes beyond the category of patients in permanent vegetative state or minimally conscious state who have previously been the subject of court applications, and also covers decisions for patients with neurodegenerative conditions and patients who have suffered a sudden onset brain injury in addition to having multiple comorbidities or general frailty which is likely to impact on life expectancy. It provides a clear statement of doctors’ legal responsibilities, covers the importance of robust best interests’ assessments and sets out the process to be followed for sufficient independent scrutiny of decisions. In light of some of the identified problems with decisions about CANH, a particular focus of the guidance is on the importance of regular best interests’ assessments, and it provides detailed practical guidance about how to approach these. The development of …. (shrink)

Many Western nations are emphasizing the importance of population health across health care delivery organizations and education systems. Despite significant momentum to integrate population health into nursing practice, a parallel effort to examine how these efforts impact practicing nurses' views of their professional role and work identity has not occurred. This secondary qualitative analysis, employing an abductive approach, explored processes public health nurses use in creating and maintaining their work identity through three organizing themes: narrative (...) self‐identity, mandated identity, and identity as struggle. The analysis was based on interview data collected from 30 US public health nurses residing in 17 states. ‘Being a real nurse’ describes public health nurses' efforts to balance a contradictory work identity where at times they are expected to focus on populations and at other times, on individuals. The identity work revealed through this study should be further explicated and specific strategies developed for stabilizing a work identity for public health nurses, as well as for any nurse charged with a population health role. (shrink)

GILLETT K. Nursing Inquiry 2010; 17: 197–207From ‘part of ’ to ‘partnership’: the changing relationship between nurse education and the National Health ServiceWorldwide, many countries have moved towards incorporating nurse education into the higher education sector and this inevitably has implications for the relationship between nurse education providers and local health service providers. This study explores the changes to the relationship in the UK between nurse education providers and the UK National Health Service over (...) the past 20 years and demonstrates how two political ideologies have been central to those changes. The two ideologies of interest are the introduction of internal markets to the National Health Service by the Conservative government at the end of the 1980s and the New Labour response to the fragmentation of public services caused by Conservative neoliberal policy, which was to introduce the notion of ‘partnership working’. This study reviews the wider debate around partnership policy and applies that debate to evaluate the way that nurse education providers and the National Health Service are working in partnership to provide clinical practice placements for nursing students. (shrink)

Effective public health nursing relies on the development of responsive and collaborative relationships with families. While nurse–family relationships are endorsed by home visitation programs, training nurses to follow visit‐to‐visit protocols may unintentionally undermine these relationships and may also obscure nurses’ clinical understanding and situated knowledge. With these issues in mind, we designed a home‐visiting intervention, titled Listening with Care, to cultivate nurses’ relationships with teen mothers and nurses’ clinical judgment and reasoning. Rather than using protocols, the training (...) for the intervention introduced nurses to narrative methods and therapeutic tools. This mixed‐method pilot study included a quasi‐experimental design to examine the effect of the intervention on teen mothers’ depressive symptoms, self‐silencing, repeat pregnancy, and educational progress compared to teens who received usual care. Qualitative data were collected from the nurses to evaluate the feasibility and acceptability of the intervention and therapeutic tools. The nurses endorsed the therapeutic tools and expected to continue using them in their practice. Despite the lack of statistically significant differences in outcomes between groups, findings suggest that further study of the intervention is warranted. Future studies may have implications for strengthening hidden aspects of nursing that make a difference in the lives of teen mothers. (shrink)