Leadership perceptions of nurse practitioners

Education in leadership principles is included in Master's Degree programs for nurse practitioners (NPs). NPs have an opportunity to be leaders in a variety of roles and to make major decisions within their profession and within the healthcare system. NPs' collaboration with nursing professionals, colleagues, and other healthcare professionals--including clients and families--demonstrate their expanded practice. The purpose of this study was to examine perceptions of leadership by Master's-prepared NPs and determine if they are providing leadership in practice. There has been minimal research to evaluate whether NPs graduating from Master's programs are effectively using leadership skills in their practice. Master's Degree education has a strong focus on leadership and, combined with the need for lower cost of healthcare, NPs have the potential to provide important leadership and cost savings to the healthcare delivery system.     

Moral distress and moral courage in everyday nursing practice

In this article the author examines the concepts of moral distress and moral courage within the context of nursing practice. Examples of challenging healthcare situations from the United Kingdom and Ireland are discussed in the light of the examination of these two concepts. The examples illuminate features of healthcare situations that need to be considered in relation to different organisational and cultural contexts. This requires an understanding of the complexity of clinical contexts and an appreciation of the fallibility and vulnerability of nurses and other practitioners. The goal of this article is to encourage healthcare organisations to create supportive structures and sensitive leadership that will enhance moral courage in the work setting.     

"Stop the noise!" From voice to silence

Nurses are frequently portrayed in the literature as being silent about ethical concerns that arise in their practice. This silence is often represented as a lack of voice. However, in our study, we found that nurses who responded to questions about moral distress were not so much silent as silenced. These nurses were enacting their moral agency by engaging in diverse, multiple and time-consuming actions in response to situations identified as morally distressing with families, colleagues, physicians, educators or managers. In many situations, they took action by contacting other healthcare team members, making referrals and coordinating care with other departments such as home care and hospice, as well as initiating contact with groups such as professional regulatory bodies or unions. Examining the relationship between ethical climate, moral distress and voice offers insights into both the meaning and impact of being silenced in the workplace.     

The faceless encounter: ethical dilemmas in telephone nursing

Aim. This paper aims to present the findings of a study designed to describe ethical dilemmas, in the form of conflicting values, norms and interests, which telenurses experience in their work. Background. Telephone nursing is an expanding part of health care. Telephone nurses in Sweden assess care needs, provide advice, support and information, and recommend and coordinate healthcare resources. Lately, ethical demands on healthcare professionals in general have increased. The reasons include new biomedical competence, an ageing population and constrained resources which have made priority setting a primary concern for doctors and nurses. When ethical problems arise, colleagues need open dialogue. Despite this, nurses lack such a dialogue. Method. A purposeful sample of 12 female telenurses in Sweden was interviewed twice during 2004 and 2005. The transcribed interviews were analysed thematically. Results. Five themes were found: talking through a third party; discussing personal and sensitive problems over the phone; insufficient resources and the organization of health care; balancing callers’ information needs with professional responsibility; and differences in judging the caller's credibility. Conclusion. The present study has identified five different themes in which Swedish telenurses experience ethical dilemmas in their work. This shows how ethical dilemmas in various forms are present in telenursing. Questions of autonomy, integrity and prioritizing are particularly highlighted by the participating nurses. Telenurses in Sweden also experience new ethical demands due to a multicultural society. Although several of the identified dilemmas also occur in other areas of nursing we argue that these situations are particularly challenging in telenursing. Relevance to clinical practice. The work organization should provide opportunities for ethical competence‐building, where ethical dilemmas in telenursing are highlighted and discussed. Such a strategy might lead to decreased moral uncertainty and distress among telenurses, with positive consequences for callers.     

Articulating nursing in an interprofessional world

It is essential that nurses in practice clearly articulate their role in interprofessional clinical settings. Assumptions, stereotypes, power differentials and miscommunication can complicate the interaction of healthcare professionals when clarity does not exist about nurses' knowledge, skills and roles. Conflicting views among nurse scholars as to the nature of nursing knowledge and its relationship to practice complicate the task of nurses in explaining their performance and role to others in interprofessional environments. Interprofessionality is potentially misunderstood by nurse leaders, practitioners and educators, isolating nurses in an increasingly inter-disciplinary healthcare system. The theorization of contemporary nursing is explored through the views and perspectives of current nurse scholars. The ability to explain nursing knowledge, skills and roles to others in interprofessional interactions is a nursing competency, as well as an interprofessional one. Nurses, nurse leaders and nurse educators are challenged to engage in interprofessionalism so as to have an influence in the evolution of healthcare education and practice environments.     

Moral distress experienced by care leaders’ in older adult care: A qualitative study

Background

Many healthcare professionals have left their professions recently because of increased moral distress, and the COVID-19 pandemic has had a further major impact on the ever-changing healthcare environment.

Aim

The purpose of the study was to examine care leaders’ experiences of moral distress in their daily work in older adult care.

Methodology

A qualitative design was used. The data consisted of texts from interviews with care leaders (N = 8) in an older adult care context. Content analysis was used to analyse the data.

Findings

Five themes emerged: (1) moral distress arises from a lack of time, (2) moral distress contributes to a sense of inadequacy but also a sense of responsibility, (3) moral distress arises from an imbalance in values, (4) increased knowledge and open discussion help reduce moral distress and (5) reflection, increased support and increased resources can reduce moral distress.

Conclusion

Moral distress is something that care leaders, according to this study, experience daily in an older adult care context and it is considered to have increased. Care leaders can experience moral distress from a lack of time; patient-related, relative-related or other ethically difficult situations or an imbalance between own values and an organisation's, other caregivers’, patients’ and/or patients’ relatives values. Increased staffing resources, more knowledge (training and lectures) and time for reflection individually, in groups or with an outside expert could increase care leaders’ insights into and ability to reduce moral distress. Although situations that are characterised by moral distress are burdensome, care leaders have the opportunity to learn from such situations through reflection and discussion and can develop strategies for future ethical challenges. Future research could focus on exploring caregivers’ experiences of moral distress.     

The use of inter-professional education (IPE) healthcare law and ethics scenario based learning sessions amongst nursing,midwifery and law students: An evaluation

BackgroundLitigation and disciplinary action taken by the Nursing and Midwifery Council (NMC) against nurses’ remains a concern with costs of claims against the NHS increasing by 72% over the five years up to 2015/16 with almost £1.5 billion spent in one year alone. Additionally, 5476 referrals regarding registrants' fitness to practice were made to the NMC in 2016–2017. The aims of this paper are to discuss how a pair of scenario based IPE sessions focussed on healthcare law and ethical topics were introduced as an addition to the existing nursing and midwifery curricula and to report the evaluation of these sessions.MethodsTwo scenario based sessions attended by nursing, midwifery and law students were delivered as an addition to existing nursing, midwifery and law curricula. The scenarios were based on real life cases and students collaborated to identify means of managing legal and ethical issues arising from the scenarios. These sessions were facilitated by lecturers from the schools of law, midwifery and nursing.FindingsAll attending students completed an evaluation questionnaire. Student evaluations indicated that the experience of working through the scenarios with their colleagues from other disciplines had enabled them to gain further knowledge and understanding around healthcare law and ethics. Student evaluations indicated a high level of engagement and interest in the subject and also drew attention to the supportive structure of the IPE sessions.ConclusionNurses and midwives continue to be called to account by both their professional body and in law for issues related to their practice. A way to enable students to consider this and aid their preparation for clinical and professional practice is through the use of clinically and professionally relevant healthcare law and ethics scenarios in IPE sessions.     

Ethical and moral considerations of (patient) centredness in nursing and healthcare: Navigating uncharted waters

This discussion paper aims to explore potential ethical and moral implications of (patient) centredness in nursing and healthcare. Healthcare is experiencing a philosophical shift from a perspective where the health professional is positioned as the expert to one that re‐centres care and service provision central to the needs and desires of the persons served. This centred approach to healthcare delivery has gained a moral authority as the right thing to do. However, little attention has been given to its moral and ethical theoretical grounding and potential implications for nurses, persons served and the healthcare system. Based upon a review of academic and grey literature, centredness is proposed as a value‐laden concept in nursing inquiry. Potential moral and ethical implications of centredness on nurses/healthcare providers, persons served and the healthcare system are discussed. These challenges are then considered within the context of normative and relational ethical theories. These perspectives may offer guidance relative to how one should act in those circumstances as well as an understanding as to how interdependency and engagement with the other person(s) can help navigate the challenges of a centred care approach. Viewing centredness through an ethical theoretical lens provides a valuable discourse to nursing in efforts to expand the knowledge base and integrate centred approaches into practice and policy.     

Listening to nurses' moral voices: building a quality health care environment

In this paper we describe a research project in nursing ethics aimed at exploring the meaning of ethics for nurses providing direct care with clients. This was a practice-based project in which participants who were staff nurses, nurses in advanced practice, and students in nursing were asked to tell us (or describe to us) how they thought about ethics in their practice, and what ethical practice meant to them. We then undertook to analyze, describe and understand the enactment of ethical practice, the opportunities for and barriers to such enactment, as well as the resources nurses need for ethical practice. We drew out implications of these findings for nursing leaders. We identified practice realities that create a climate for ethical or moral distress, and the way in which nurses attempt to maintain their moral agency. Practice realities included nurses' ethical concerns about policies guiding care; the financial, human and temporal resources available for care; and the power and conflicting loyalties nurses encounter inproviding good care. Maintaining moral agency involved use of a variety of ethical resources and the identification of resources needed to provide good care, as well as the processes used to enact moral agency. Nurse leaders are also moral agents. Important implications of these findings for nursing leaders are that they need moral courage to be self-reflective, to name their own moral distress, and to act so that their nursing staff are able to be moral agents. Nurse leaders need to be the moral compass for nurses, using their power as a positive force to promote, provide and sustain quality practice environments for safe, competent and ethical practice.     

Ethics in critical care in nursing

The ANA Code for Nurses requires ethical behavior from all practitioners of nursing. As such, it serves to safeguard the public from unethical nurses. However, the code cannot and does not give direction in all situations nurses encounter in practice. Nurses require more assistance to meet the ethical requirements of professional practice. Careful exploration of moral principles and theories affords the nurse a broad background and some specific insights into morality and moral decision making. However, even this knowledge does not allow any nurse to put her ethical self "on automatic" while she appeals to one or another of these principles to support what she decides to do. No moral theory or principle is absolute. None can be used exclusively to resolve the many ethical questions nurses face. A nurse must use the process of reflective equilibrium to balance her own moral convictions and her background beliefs with accepted moral theories and principles, in order to reach sound moral judgements.     

Engaging Beyond the Bedside Nurses in a Large Pediatric Health Care System

Health care systems have a growing need to expand the nursing role to meet the needs of the patients and the community they serve. As the nursing role expands beyond clinical operations, there is a greater gap in connecting with other nursing colleagues. Additionally, engaging all nurses throughout health care systems is a challenging task for nursing leaders. This article offers a systematic way to identify and engage nurses working in positions beyond the bedside (BTB) within a large health care system. Nursing leaders implemented an initiative to connect BTB nurses to the chief nursing officer and the nursing strategic plan. Nursing leaders created innovative ways to engage, connect, and professionally develop BTB nurses within the healthcare system.     

Navigating towards a moral horizon: a multisite qualitative study of ethical practice in nursing.

This paper reports the results of a qualitative study of nurses' ethical decision-making. Focus groups of nurses in diverse practice contexts were used as a means to explore the meaning of ethics and the enactment of ethical practice. The findings centre on the metaphor of a moral horizon--the horizon representing "the good" towards which the nurses were navigating. The findings suggest that currents within the moral climate of nurses' work significantly influence nurses' progress towards their moral horizon. All too often, the nurses found themselves navigating against a current characterized by the privileging of biomedicine and a corporate ethos. Conversely, a current of supportive colleagues as well as professional guidelines and standards and ethics education helped them to move towards their horizon. The implications for nursing practice and for our understanding of ethical decision-making are discussed.     

Review: the legal duty of care for nurses and other health professionals

Aims and objectives. To explore the nature and extent of the legal duty of care in relation to contemporary healthcare practice. Background. The paper seeks to re‐frame and update the legal duty of care for clinical nursing practice in the 21st century, taking into account collaborative and partnership working in healthcare practice. Design. Doctrinal legal ‘approach’. Method. ‘Black letter’ legal research methodology used for data collection and analysis. Literature search using Westlaw and LexisNexis database(s) to identify recent common law decisions. Results. There has been a perceptible doctrinal shift away from paternalism and toward patient empowerment and autonomy in the last decade. This has implications for nurses and other healthcare professionals in terms of consenting patients and acting reasonably to ensure quality patient care. Conclusions. A number of experienced nurses are currently assuming extended roles and some are completing medical tasks, traditionally allocated to doctors. These specialist practitioners must remember that additional responsibility invariably means increased professional risk and accountability. Therefore, it is essential that those engaging in advanced nursing practice, fully understand the nature and reach of their professional duty of care and the significance of statutory and common law developments. Relevance to clinical practice. Nurses and other healthcare professionals must update their clinical skills and practice within a legal framework and to certain standards. The cases cited and discussed are relevant to all branches of nursing and indeed to all health professions.     

Ethical dilemmas and moral distress in oncology nursing practice

Although ethical values and principles guide oncology nursing practice, nurses often are challenged to fulfill every professional core duty and responsibility in their everyday practice. Nurses commonly encounter clinical situations that have ethical conflicts, and they often have difficulty recognizing and articulating them. Unresolved conflicts can cause feelings of frustration and powerlessness, which can lead to compromises in patient care, job dissatisfaction, disagreements among those in the healthcare team, and burnout. This article reviews the ethical principles and values individual nurses bring to their practice as well as those basic to the profession of nursing. This article also discusses ethical conflicts in oncology practice and describes how nurses, especially students and novice nurses, may react to such situations with moral uncertainty or distress. In addition, a process for analyzing and resolving ethical problems in clinical situations is outlined. Increasing awareness and dialogue about ethical issues is an important first step in the process. Additional resources in the clinical setting may encourage nurses to actively participate in ethical decision making and take deliberate action as moral agents.     

Evidence-based practice and evidence-informed practice competencies in undergraduate pre-registration nursing curricula: A document analysis at a university in England

BackgroundIn response to the heightened emphasis on incorporating the best available evidence into healthcare decision-making, healthcare training institutions have been actively incorporating Evidence-Based Practice (EBP), and/or Evidence-Informed Practice (EIP) competencies into undergraduate healthcare curricula. However, there is a gap in the scientific knowledge about the actual contents, as well as the extent of integration of EBP and EIP in undergraduate pre-registration nursing programmes.MethodA document analysis utilising Rohwer et al.’s (2014) framework was conducted to review and analyse the content of EBP and EIP competencies in the 2018/2019 curriculum of the undergraduate pre-registration nursing programme of a University located in England, United Kingdom.ResultsCompetencies relevant to EBP were included in four nursing modules. However, EIP competencies were not included in the curriculum.ConclusionThere is an urgent need for a more structured and holistic way of teaching and assessing EBP competencies through the integration of the principles of EIP, in order to enhance the effective application of evidence into clinical nursing practice.     

Increasing nursing research capacity: The roles and contributions of nurse scientists within healthcare systems in the Greater Philadelphia region

PhD prepared nurse scientists within healthcare systems are uniquely positioned to advance nursing science through research and evidence-based practice (EBP) initiatives due to their ability to closely collaborate with nurses and other healthcare professionals in the clinical setting. The purpose of this paper is threefold: 1) to describe the roles and contributions of Nurse Scientists, from their perspectives, in four different health care systems in the Greater Philadelphia area, three of which are Magnet® designated hospitals; 2) to highlight organizational approaches to increase nursing research and EBP capacity; and 3) to explore strategies that Nurse Scientists used to overcome barriers to build nursing research capacity. Nurse Scientists employed in these healthcare systems share many of the same essential roles and contributions focused on developing nursing research and EBP initiatives through education and mentorship of clinical nurses, conduct and oversight of independent research, and dissemination activities. With supportive executive nurse leadership, the Nurse Scientists within each healthcare system employed different strategies to overcome barriers in building nursing research and EBP capacity. Nurse scientists within healthcare settings have potentially powerful positions to generate and apply new knowledge to guide nursing practice and improve outcomes.     

Canadian nursing in the genomic era: a call for leadership

With developments in genomics, there is an urgent need for Canadian nurses in all settings to be informed and involved in the incorporation of this new knowledge into healthcare. The purpose of this paper was to synthesize the literature on genetic nursing roles to provide a foundation for Canadian nursing leaders as they take on the challenges of nursing in the genomic era. A comprehensive review of 98 articles published between 1994 and 2004 revealed strong support for genetic nursing roles and recommendations for levels of genetic nursing practice. The few studies on genetic nursing roles suggested that nurses and other health professionals support the integration of genomics into nursing practice. Issues that need to be addressed related to nursing practice, education and research are offered to engage nursing leaders in advocating for the incorporation of genomics into nursing in Canada.     

Information and human freedom: nursing implications and ethical decision-making in the 21st century

With globalization and the increasing volume of healthcare information available to people, questions surface as nurses contemplate and envision what role and how our nursing theory-guided discipline ought to be lived with colleagues of other disciplines, each other, and those we serve in the 21(st) century. This column begins a path of ethical exploration and possible implications for the opportunities and challenges associated with the information age in nursing research, practice, and education. Discussion focuses on the disciplinary responsibilities for information giving and receiving; coming to know, human freedom, and decision-making in the human-universe-health process.