http://nej.sagepub.com Nursing Ethics RSS feed -- recent issues Nursing Ethics 0969-7330 http://nej.sagepub.com:80/icons/banner/title.gif http://nej.sagepub.com http://nej.sagepub.com/cgi/reprint/15/5/569?rss=1 2008-08-07 info:doi/10.1177/0969733008092866 5 15 570 2008-09-01 569 Article http://nej.sagepub.com/cgi/reprint/15/5/571?rss=1 2008-08-07 info:doi/10.1177/0969733008092867 5 15 572 2008-09-01 571 Article http://nej.sagepub.com/cgi/content/abstract/15/5/573?rss=1 This study investigated 204 doctors' and nurses' perceived knowledge of bloodborne pathogens and their attitudes towards bloodborne pathogen-infected health care workers. A structured questionnaire examined: (1) their perceived knowledge of bloodborne pathogens; (2) their attitudes towards bloodborne pathogen-infected personnel; and (3) their opinions on limitation of employment of bloodborne pathogen-infected personnel and restrictions on performing clinical procedures. The levels of HIV-related knowledge were significantly higher than for hepatitis C and B viruses. Although the participants demonstrated more positive attitudes towards hepatitis C- and B-infected health care workers, 64% recommended restricting infected personnel from performing invasive procedures. Attitudes were negatively correlated with opinions on restricting infected personnel from health care work or limiting their involvement in clinical activities. This study highlights the need to formulate a policy to cope with the professional and moral dilemmas related to infected health care workers employed in hospitals, especially for those involved in invasive procedures.

]]> 2008-08-07 info:doi/10.1177/0969733007088362 5 15 585 2008-09-01 573 Article http://nej.sagepub.com/cgi/content/abstract/15/5/586?rss=1 This study aims to describe and compare nurses' willingness to provide care for patients with HIV/AIDS and factors associated with this in three countries. An international cross-sectional survey was conducted among nurses working in medical, surgical and gynaecology units in Finland (n =427), Estonia (n =221) and Lithuania ( n =185) in early 2006. The response rates were 75% (n = 322) in Finland, 54% (n =119) in Estonia and 86% (n = 160) in Lithuania. A modified version of a scale developed in 1994 by Dubbert et al. was applied. Our findings showed a general willingness of the nurse participants to provide care for patients with HIV/AIDS. However, this willingness varied both among and within countries and was also related to specific nursing interventions. The results underline the importance of providing education on ethical issues related to HIV/AIDS care in Europe and tailoring the content of this education to meet nurses' national educational needs.

]]> 2008-08-07 info:doi/10.1177/0969733008092868 5 15 600 2008-09-01 586 Article http://nej.sagepub.com/cgi/content/abstract/15/5/601?rss=1 Key words: code of ethics; rejected patients; terrorism; terrorist victims; terrorists; values

]]> 2008-08-07 info:doi/10.1177/0969733008092869 5 15 613 2008-09-01 601 Article http://nej.sagepub.com/cgi/content/abstract/15/5/614?rss=1 The purpose of this study was to measure professional and personal values among nurses, and to identify the factors affecting these values. The participants were 323 Israeli nurses, who were asked about 36 personal values and 20 professional values. The three fundamental professional nursing values of human dignity, equality among patients, and prevention of suffering, were rated first. The top 10 rated values all concerned nurses' responsibility towards patients. Altruism and confidentiality were not highly rated, and health promotion and nursing research were rated among the last three professional values. For personal (instrumental) values, honesty, responsibility and intelligence were rated first, while ambition and imagination were rated 14th and 16th respectively out of 18. Significant differences (P < 0.05) were found among some personal and professional values rated as functions of culture, education, professional seniority, position and field of expertise. The results may assist in understanding the motives of nurses with different characteristics and help to promote their work according to professional ethical values.

]]> 2008-08-07 info:doi/10.1177/0969733008092870 5 15 630 2008-09-01 614 Article http://nej.sagepub.com/cgi/content/abstract/15/5/631?rss=1 This study aims to unveil the process of whistleblowing. Two nursing staff members who worked in a psychiatric hospital convicted of large-scale wrongdoing were interviewed. Data were analyzed using a modified grounded theory approach. Analysis of the interviews demonstrated that they did not decide to whistleblow when they were suspicious or had an awareness of wrongdoing. They continued to work, driven by appreciation, affection, and a sense of duty. Their decision to whistleblow was ultimately motivated by firm conviction. Shortly after whistleblowing, wavering emotions were observed, consisting of a guilty conscience, fear of retribution, and pride, which subsequently transformed to stable emotions containing a sense of relief and regret for delayed action. It is necessary for nurses to recognize that their professional responsibility is primarily to patients, not to organizations. Nurses should also have professional judgment about appropriate allegiance and actions.

]]> 2008-08-07 info:doi/10.1177/0969733008092871 5 15 642 2008-09-01 631 Article http://nej.sagepub.com/cgi/content/abstract/15/5/643?rss=1 In April 2004 the Irish Government commissioned Judge Maureen Harding Clark to compile a report to ascertain the rate of caesarean hysterectomies at Our Lady of Lourdes Hospital in Drogheda, Republic of Ireland. The report came about as a result of complaints by midwives into questionable practices that were mainly (but not solely) attributed to one particular obstetrician. In this article we examine the findings of this Report through a feminist lens in order to explore what a feminist reading of the Report and the events that led to the inquiry will bring to light. We consider how sex and gender feature in the Lourdes case, draw attention to the deeply gendered asymmetries of power and privilege that existed between the men and women at the centre of this inquiry, and explore the impact such asymmetries had on this particular situation.

]]> 2008-08-07 info:doi/10.1177/0969733008092873 5 15 655 2008-09-01 643 Article http://nej.sagepub.com/cgi/content/abstract/15/5/656?rss=1 Ethical problems surrounding organ donation have been discussed since before technologies supported the procedure. In addition to issues on a societal level (e.g. brain-stem death, resource allocation), ethical concerns permeate the clinical practice of health care staff. These latter have been little studied. Using qualitative methods, this study, focused on transplant co-ordinators and their descriptions of dilemmas, ethical concerns and actions in response to them. Interviews with three co-ordinators in Japan and two in the UK revealed five areas in which dilemmas occurred: aspects of discrimination; conditions placed on who should be the recipient and the related issues of directed donation; respect for a person's right to make a decision and the extent of information provided and understood by donors and recipients; potential issues of coercion, compensation and rewards in live-related and live-unrelated donations; and potential conflicts in duties. This study describes the dilemma areas revealed. Their meaning for co-ordinators will be presented in a subsequent report.

]]> 2008-08-07 info:doi/10.1177/0969733008092874 5 15 669 2008-09-01 656 Article http://nej.sagepub.com/cgi/content/abstract/15/5/670?rss=1 This study focuses on investigating habits in perioperative nursing culture, which are often simply accepted and not normally considered or discussed. A hermeneutical approach was chosen as the means of understanding perioperative nurses' experiences of and reflections on operating theatre culture. Focus group discussions were used to collect data, which was analysed using hermeneutical text analysis. The results revealed three main categories of habits present in perioperative nursing culture: habits that promote ethical values (by temporary friendship with patients, showing respect for each other, and spending time on reflection on ethics and caring); habits that hinder progress (by seeing the patient as a surgical case, not acknowledging colleagues, and not talking about ethics); and habits that set the cultural tone (the hidden power structure and achieving more in less time).

]]> 2008-08-07 info:doi/10.1177/0969733008092875 5 15 681 2008-09-01 670 Article http://nej.sagepub.com/cgi/content/abstract/15/5/682?rss=1 This article reports the findings of a study into the role of Dutch nurses in the alleviation of pain and symptoms with a life-shortening intention, conducted as part of a study into the role of nurses in medical end-of-life decisions. A questionnaire survey was carried out using a population of 1509 nurses who were employed in hospitals, home care organizations and nursing homes. The response rate was 82.0%; 78.1% (1179) were suitable for analysis. The results show that in about half of the cases (55.8%) nurses were involved in the decision making by the physician and that nurses were frequently (81.5%) involved in administering the medication. The authors' conclusion is that alleviation of pain and symptoms with a life-shortening intention represents a `grey' area, in which physicians and nurses act on the basis of personal ethical norms rather than legal rules, professional guidelines or shared moral values.

]]> 2008-08-07 info:doi/10.1177/0969733008092876 5 15 695 2008-09-01 682 Article http://nej.sagepub.com/cgi/reprint/15/5/696?rss=1 2008-08-07 info:doi/10.1177/0969733008092877 5 15 697 2008-09-01 696 Article http://nej.sagepub.com/cgi/reprint/15/5/697?rss=1 2008-08-07 info:doi/10.1177/0969733008093821 5 15 699 2008-09-01 697 Article http://nej.sagepub.com/cgi/reprint/15/5/700?rss=1 2008-08-07 info:doi/10.1177/0969733008092880 5 15 702 2008-09-01 700 Article http://nej.sagepub.com/cgi/reprint/15/5/703?rss=1 2008-08-07 info:doi/10.1177/09697330080150051302 5 15 704 2008-09-01 703 Article http://nej.sagepub.com/cgi/reprint/15/5/703-a?rss=1 2008-08-07 info:doi/10.1177/0969733008092878 5 15 703 2008-09-01 703 Article http://nej.sagepub.com/cgi/reprint/15/5/704?rss=1 2008-08-07 info:doi/10.1177/09697330080150051303 5 15 705 2008-09-01 704 Article http://nej.sagepub.com/cgi/reprint/15/5/706?rss=1 2008-08-07 info:doi/10.1177/09697330080150051304 5 15 706 2008-09-01 706 Article http://nej.sagepub.com/cgi/reprint/15/5/707?rss=1 2008-08-07 info:doi/10.1177/0969733008092879 5 15 708 2008-09-01 707 Article http://nej.sagepub.com/cgi/reprint/15/4/427?rss=1 2008-05-30 info:doi/10.1177/0969733008090511 4 15 428 2008-07-01 427 Article http://nej.sagepub.com/cgi/reprint/15/4/429?rss=1 2008-05-30 info:doi/10.1177/0969733008090512 4 15 430 2008-07-01 429 Article http://nej.sagepub.com/cgi/reprint/15/4/431?rss=1 2008-05-30 info:doi/10.1177/0969733008090513 4 15 433 2008-07-01 431 Article http://nej.sagepub.com/cgi/content/abstract/15/4/434?rss=1 This article is presented as a defence of voluntary active euthanasia from a virtue perspective and it is written with the objective of generating debate and challenging the assumption that killing is necessarily vicious in all circumstances. Practitioners are often torn between acting from virtue and acting from duty. In the case presented the physician was governed by compassion and this illustrates how good people may have the courage to sacrifice their own security in the interests of virtue. The doctor's action created huge tensions for the nurse, who was governed by the code of conduct and relevant laws. Appraising active euthanasia from a virtue perspective can offer a more compassionate approach to the predicament of practitioners and clients. The tensions arising from the virtue versus rules debate generates irreconcilable difficulties for nurses. A shift towards virtue would help to resolve this problem and support the call for a change in the law. The controversial nature of this position is acknowledged. The argument is put forward on the understanding that many practitioners will not agree with the conclusions reached.

]]> 2008-05-30 info:doi/10.1177/0969733008090514 4 15 445 2008-07-01 434 Article http://nej.sagepub.com/cgi/reprint/15/4/446?rss=1 2008-05-30 info:doi/10.1177/0969733008090515 4 15 449 2008-07-01 446 Article http://nej.sagepub.com/cgi/reprint/15/4/449?rss=1 2008-05-30 info:doi/10.1177/0969733008090516 4 15 451 2008-07-01 449 Article http://nej.sagepub.com/cgi/reprint/15/4/451?rss=1 2008-05-30 info:doi/10.1177/0969733008090653 4 15 456 2008-07-01 451 Article http://nej.sagepub.com/cgi/content/abstract/15/4/457?rss=1 Patient advocacy has been a topic of much discussion in the nursing literature for a number of decades. Ambiguities remain, however, concerning definitions of advocacy in nursing. This qualitative grounded theory-type study aimed to inquire into the meaning of patient advocacy from Iranian nurses' perspective. A purposive sample of 24 nurses (staff nurses, head nurses and supervisors) working in a large university hospital in Tehran was used. Data were collected using in-depth semistructured interviews and reflective diaries kept by the participants. The data were analyzed using elements of Strauss and Corbin's' approach. Advocacy was defined by the participants as: informing and educating; valuing and respecting; supporting; protecting; and promoting continuity of care for patients. The participants also believed that advocacy could take place only if there was respect for patients' individuality and their inherent human dignity. Many of the descriptions given by the participants are consistent with previous research in this area and represent a comprehensive account of their perceptions of patient advocacy.

]]> 2008-05-30 info:doi/10.1177/0969733008090517 4 15 467 2008-07-01 457 Article http://nej.sagepub.com/cgi/content/abstract/15/4/468?rss=1 Nursing advocacy for patients is considered to be an essential component of nursing practice. This phenomenological qualitative pilot study explored registered nurses' lived experience of nursing advocacy with patients using a sample of three medical-surgical registered nurses. The guiding research questions were: (1) how do registered nurses practicing in the medical-surgical specialty area describe their experiences with nursing advocacy for their patients; and (2) what reflections on educational preparation for their professional roles do registered nurses identify as related to their practices of nursing advocacy with their patients? Data analysis procedures were based on Moustakas' data analysis method, and Lincoln and Guba's criteria were applied for rigor. The emergent themes were: speaking out and speaking for patients; being compelled to act on unmet needs of patients; fulfillment and frustration; the patient is changed; primarily learned on the job; and confidence gained through practice. The findings increase the body of knowledge surrounding nursing advocacy as practiced by nurses.

]]> 2008-05-30 info:doi/10.1177/0969733008090518 4 15 477 2008-07-01 468 Article http://nej.sagepub.com/cgi/content/abstract/15/4/478?rss=1 The aim of this study was to describe Tanzanian nurses' meaning of and experiences with ethical dilemmas and workplace distress in different care settings. An open question guide was used and the study focused on the answers that 29 registered nurses supplied. The theme, `Tanzanian registered nurses' invisible and visible expressions about existential conditions in care', emerged from several subthemes as: suffering from (1) workplace distress; (2) ethical dilemmas; (3) trying to maintaining good quality nursing care; (4) lack of respect, appreciation and influence; and (5) a heavy workload that did not prevent registered nurses from struggling for better care for their patients. The analysis shows that, on a daily basis, nurses find themselves working on the edge of life and death, while they have few opportunities for doing anything about this situation. Nurses need professional guidance to gain insight and be able to reflect on their situations, so that they do not become overloaded with ethical dilemmas and workplace distress.

]]> 2008-05-30 info:doi/10.1177/0969733008090519 4 15 491 2008-07-01 478 Article http://nej.sagepub.com/cgi/content/abstract/15/4/492?rss=1 A literature review of 98 articles concerning clinical pain research in newborn infants was conducted to evaluate how researchers report the ethical issues related to their studies and how journals guide this reporting. The articles were published in 49 different scientific journals. The ethical issues most often mentioned were parental informed consent (94%) and ethical review approval (87%). In 75% of the studies the infants suffered pain during the research when placebo, no treatment or otherwise inadequate pain management was applied. Discussion about benefits versus harm to research participants was lacking. A quarter of the journals did not have any ethical guidelines for submitted manuscripts. We conclude that ethical considerations did not play a significant role in the articles studied. Missing and superficial guidelines enable authors to offer studies with fragile research ethics.

]]> 2008-05-30 info:doi/10.1177/0969733007086017 4 15 499 2008-07-01 492 Article http://nej.sagepub.com/cgi/content/abstract/15/4/500?rss=1 The aim of this study was to understand how mothers experienced midwives' uncaring behaviour and actions during birth. Sixty-seven first-time mothers took part in the study, in which data were collected through interview. The interview text was analysed using hermeneutic text analysis. Nearly half of the mothers interviewed (n = 32) said that midwives did not care for them. The findings show that midwives' behaviour was humiliating when they ignored mothers and held them in contempt. The mothers felt further humiliated when the midwives did not believe them, treated their bodies in a careless manner and tended to put blame on them. Through their behaviour and actions, some midwives have shown that they no longer have a caring attitude as an element of their professional practice and that they have ignored ethics by offending mothers' sense of dignity.

]]> 2008-05-30 info:doi/10.1177/0969733008090521 4 15 511 2008-07-01 500 Article http://nej.sagepub.com/cgi/content/abstract/15/4/512?rss=1 Persons exhibiting mutations in two tumor suppressor genes, BRCA1 and BRCA2, have a greatly increased risk of developing breast and/or ovarian cancer. The incidence of BRCA gene mutation is very high in Ashkenazi Jewish women of European descent, and many issues can arise, particularly for observant Orthodox women, because of their genetic status. Their obligations under the Jewish code of ethics, referred to as Jewish law, with respect to the acceptability of various risk-reducing strategies, may be poorly understood. In this article the moral direction that Jewish law gives to women regarding testing, confidentiality, and other issues is explored. The intent is to broaden nurses' knowledge of how a particular religious tradition could impact on decision making around genetics testing, with the aim of enhancing their understanding of culturally sensitive ethical care.

]]> 2008-05-30 info:doi/10.1177/09697330080150041201 4 15 522 2008-07-01 512 Article http://nej.sagepub.com/cgi/content/abstract/15/4/523?rss=1 This study aimed to describe and compare the views of nurses and older patients' relatives on factors restricting the maintenance of patient integrity in long-term care. The purposive sample comprised 222 nurses and 213 relatives of older patients in four Finnish long-term care institutions. The data were collected using a self-developed questionnaire addressing five sets of factors relating to patients, relatives, nurses, the organization and society. The maintenance of patient integrity was restricted by: (1) social factors, including lack of respect for long-term geriatric care and lack of adequate resources; (2) patient factors relating to forgetfulness; and (3) factors relating to nurses and relatives in maintaining patient integrity. Better maintenance of patient integrity requires that more consideration is paid to issues of social respect and to the availability of adequate resources. Closer attention must be given to patients who are forgetful and unable to take part in decision making.

]]> 2008-05-30 info:doi/10.1177/0969733008090523 4 15 535 2008-07-01 523 Article http://nej.sagepub.com/cgi/content/abstract/15/4/536?rss=1 Ethical problems regularly arise during daily care in nursing homes. These include violation of patients' right to autonomy and to be treated with respect. The aim of this study was to investigate how caregivers emphasize daily dialogue and mutual reflection to reach moral alternatives in daily care. The data were collected by participant observation and interviews with seven caregivers in a Norwegian nursing home. A number of ethical problems linked to 10 patients were disclosed. Moral problems were revealed as the caregivers acted in ways that they knew were against patients' interest. We used a theoretical interpretation according to Habermas' discourse ethics on the importance of dialogue when deciding moral courses of action for patients. This theory has four basic requirements: communicative competence, equality, self-determination, and openness about motives.

]]> 2008-05-30 info:doi/10.1177/0969733008090524 4 15 548 2008-07-01 536 Article http://nej.sagepub.com/cgi/content/abstract/15/4/549?rss=1 How nursing as a profession is valued may be changing and needs to be explored and understood in a global context. We draw on data from two empirical studies to illustrate our argument. The first study explored the value of nursing globally, the second investigated the experiences of overseas trained nurses recruited to work in a migrant capacity in the UK health care workforce. The indications are that nurses perceive themselves as devalued socially, and that other health care professionals do not give nursing the same status as other, socially more prestigious professions, such as medicine. Organizational and management structures within the NHS and the independent care home sector devalue overseas nurses and the contribution they make to health care. Our conclusions lead us to question the accepted sociocultural value of the global nursing workforce and its perceived contribution to global health care, and to consider two ethical frameworks from which these issues could be discussed further.

]]> 2008-05-30 info:doi/10.1177/0969733008090526 4 15 556 2008-07-01 549 Article http://nej.sagepub.com/cgi/reprint/15/4/557?rss=1 2008-05-30 info:doi/10.1177/0969733008090529 4 15 560 2008-07-01 557 Article http://nej.sagepub.com/cgi/reprint/15/4/561?rss=1 2008-05-30 info:doi/10.1177/0969733008090527 4 15 561 2008-07-01 561 Article http://nej.sagepub.com/cgi/reprint/15/4/562?rss=1 2008-05-30 info:doi/10.1177/09697330080150041602 4 15 562 2008-07-01 562 Article http://nej.sagepub.com/cgi/reprint/15/4/562-a?rss=1 2008-05-30 info:doi/10.1177/09697330080150041603 4 15 563 2008-07-01 562 Article http://nej.sagepub.com/cgi/reprint/15/4/563?rss=1 2008-05-30 info:doi/10.1177/09697330080150041604 4 15 564 2008-07-01 563 Article http://nej.sagepub.com/cgi/reprint/15/4/564?rss=1 2008-05-30 info:doi/10.1177/09697330080150041605 4 15 565 2008-07-01 564 Article http://nej.sagepub.com/cgi/reprint/15/4/566?rss=1 2008-05-30 info:doi/10.1177/0969733008090528 4 15 567 2008-07-01 566 Article http://nej.sagepub.com/cgi/reprint/15/3/285?rss=1 2008-04-03 info:doi/10.1177/0969733007088353 3 15 286 2008-05-01 285 Article http://nej.sagepub.com/cgi/reprint/15/3/287?rss=1 2008-04-03 info:doi/10.1177/0969733007088354 3 15 288 2008-05-01 287 Article http://nej.sagepub.com/cgi/content/abstract/15/3/289?rss=1 `Being sensitive' in nursing was explored using Schwartz-Barcott and Kim's hybrid model of concept development, producing a tentative definition of the concept. Three phases were employed: theoretical, empirical/fieldwork and analytical. An exploration of the literature identified where the common idea of `being sensitive' as a nurse was embedded and demonstrated that a theoretical development of this fundamental aspect of nursing was absent. The empirical phase was conducted using semistructured interviews with nine expert palliative care and cancer nurses. This method was particularly useful for the exploration of this concept because of its firm grounding in practical example. A definition of what the concept `being sensitive' means in nursing, and subsequent clarification of `being insensitive', have been posed from the research process undertaken. The essential nature of this concept being integral to nursing practice is emphasized. Potential implications for the development of nursing practice through teaching of this concept were identified.

]]> 2008-04-03 info:doi/10.1177/0969733007088355 3 15 303 2008-05-01 289 Article http://nej.sagepub.com/cgi/content/abstract/15/3/304?rss=1 Increased technological and pharmacological interventions in patient care when patient outcomes are uncertain have been linked to the escalation in moral and ethical dilemmas experienced by health care providers in acute care settings. Health care research has shown that facilities that are able to attract and retain nursing staff in a competitive environment and provide high quality care have the capacity for nurses to process and resolve moral and ethical dilemmas. This article reports on the findings of a systematic review of the empirical literature (1980 — February 2007) on the effects of unresolved moral distress and poor ethical climate on nurse turnover. Articles were sought to answer the review question: Does unresolved moral distress and a poor organizational ethical climate increase nurse turnover? Nine articles met the criteria of the review process. Although the prevailing sentiment was that poor ethical climate and moral distress caused staff turnover, definitive answers to the review question remain elusive because there are limited data that confidently support this statement.

]]> 2008-04-03 info:doi/10.1177/0969733007088357 3 15 321 2008-05-01 304 Article http://nej.sagepub.com/cgi/content/abstract/15/3/322?rss=1 Critical care nurses are key providers in a high acuity environment. This qualitative research study explored ethical decision making in a critical care practice setting. Fifteen critical care nurses with varying experience and education levels were purposively sampled to assure the representativeness of the data. The theoretical concepts of experiential learning, perspective transformation, reflection-in-action and principle-based ethics were used as a framework for eliciting information from the participants. A new model of focused reflection in ethical decision making was developed. Findings showed that having a role model or mentor to help guide the ethical decision-making process was critical for focused ethical discourse and the decision making.

]]> 2008-04-03 info:doi/10.1177/0969733007088430 3 15 331 2008-05-01 322 Article http://nej.sagepub.com/cgi/content/abstract/15/3/332?rss=1 This pilot study explores four nursing leaders' experiences with the ethical dimensions of leadership in education. Gathering and interpreting such data of experience fosters greater understanding of the nature of moral leadership as it is lived in nursing education. A phenomenological approach was used to collect and analyze the data. The results revealed four major themes: integrity, justice, wrestling with decisions in the light of consequences, and the power of information. These themes clarify the values that direct these leaders' actions as they mediate community needs common to educational and health care institutions.

]]> 2008-04-03 info:doi/10.1177/0969733007088358 3 15 345 2008-05-01 332 Article http://nej.sagepub.com/cgi/content/abstract/15/3/346?rss=1 The purpose of this study was to compare nursing students' perceptions of self-determination in elderly patients before and after clinical training in long term care institutions as a part of their course in gerontological nursing. A pre- post-test design was employed. The data were collected by questionnaires completed by students at one nurse education organization college in Finland (pre-test n ± 120, response rate 95%; post-test n ± 115, response rate 91%). The students' perceptions of elderly patients' self-determination were more positive after their clinical training period concerning to what extent elderly patients are able to control their treatment and what kind of support they received from nurses to exercise their self-determination. The students' perceptions remained stable concerning how important self-determination is to elderly patients, and how willing and knowledgeable they are about using their self-determination. Ethics teaching, together with high quality clinical training placements, should be assured early during nursing studies.

]]> 2008-04-03 info:doi/10.1177/0969733007088359 3 15 359 2008-05-01 346 Article http://nej.sagepub.com/cgi/content/abstract/15/3/360?rss=1 Advocacy has been positioned as an ideal within the practice of nursing, with national guidelines and professional standards obliging nurses to respect patients' autonomous choices and to act as their advocates. However, the meaning of advocacy and autonomy is not well defined or understood, leading to uncertainty regarding what is required, expected and feasible for nurses in clinical practice. In this article, a feminist ethics perspective is used to examine how moral responsibilities are enacted in the perinatal nurse—patient relationship and to explore the interaction between the various threads that influence, and are in turn affected by, this relationship. This perspective allows for consideration of contextual and relational factors that impact on the way perinatal nursing care is given and received, and provides a framework for exploring the ways in which patient autonomy, advocacy and choice are experienced by childbearing women and their nurses during labour and birth.

]]> 2008-04-03 info:doi/10.1177/0969733007088360 3 15 370 2008-05-01 360 Article http://nej.sagepub.com/cgi/content/abstract/15/3/371?rss=1 The aim of this study was to explore and interpret the diverse subject of positions, or roles, that nurses construct when caring for patients in their own home. Ten interviews were analysed and interpreted using discourse analysis. The findings show that these nurses working in home care constructed two positions: `guest' and `professional'. They had to make a choice between these positions because it was impossible to be both at the same time. An ethics of care and an ethics of justice were present in these positions, both of which create diverse ethical appeals, that is, implicit demands to perform according to a guest or to a professional norm.

]]> 2008-04-03 info:doi/10.1177/0969733007088361 3 15 383 2008-05-01 371 Article http://nej.sagepub.com/cgi/content/abstract/15/3/384?rss=1 This article draws on two studies that have used an ethic of care analysis to explore lay, nursing and social work care for people with dementia. It discusses the political as well as the practice application of ethic of care principles and highlights the necessity to understand both what people do and the meanings with which such practices are imbued in order to identify `good care' and the relationship between this and social justice. Examples of care for people with dementia are discussed by reference to core principles of an ethic of care: attentiveness, responsibility, competence, responsiveness and trust. These illustrate the potential for the development of a shared language within which different disciplines, lay carers and people with dementia can communicate about how needs could best be met in complex and difficult circumstances.

]]> 2008-04-03 info:doi/10.1177/0969733007088363 3 15 395 2008-05-01 384 Article http://nej.sagepub.com/cgi/content/abstract/15/3/396?rss=1 There is a strong association between reliance on the promotional activities of pharmaceutical companies and a generally less appropriate use of prescription drugs. Pharmaceutical companies direct some of their promotion towards health workers who do not have the authority to prescribe medicines, such as nurses in certain countries. The aim of this study was to determine the impact that exposure to the marketing methods of pharmaceutical companies has on judgments made by nursing students about health worker—pharmaceutical company relationships. A cross-sectional survey was carried out with 442 nursing students in Istanbul, Turkey. The exposure of students to the marketing methods of pharmaceutical companies, whether it be indirectly through observation or directly by first-hand experience, increases the probability that students will adopt rationales that underlie affirmative judgments of health worker—pharmaceutical company relationships. Based on the pervasiveness and ability of drug promotion to influence the perceptions of students, it is imperative that attempts be made to reduce its negative impact.

]]> 2008-04-03 info:doi/10.1177/0969733007088364 3 15 410 2008-05-01 396 Article http://nej.sagepub.com/cgi/reprint/15/3/411?rss=1 2008-04-03 info:doi/10.1177/0969733007088365 3 15 418 2008-05-01 411 Article http://nej.sagepub.com/cgi/reprint/15/3/419?rss=1 2008-04-03 info:doi/10.1177/0969733007088368 3 15 420 2008-05-01 419 Article http://nej.sagepub.com/cgi/reprint/15/3/421?rss=1 2008-04-03 info:doi/10.1177/0969733007088366 3 15 422 2008-05-01 421 Article http://nej.sagepub.com/cgi/reprint/15/3/422?rss=1 2008-04-03 info:doi/10.1177/09697330080150031202 3 15 423 2008-05-01 422 Article http://nej.sagepub.com/cgi/reprint/15/3/424?rss=1 2008-04-03 info:doi/10.1177/0969733007088367 3 15 425 2008-05-01 424 Article http://nej.sagepub.com/cgi/reprint/15/2/143?rss=1 2008-02-13 info:doi/10.1177/0969733007086011 2 15 144 2008-03-01 143 Article http://nej.sagepub.com/cgi/reprint/15/2/145?rss=1 2008-02-13 info:doi/10.1177/0969733007086012 2 15 146 2008-03-01 145 Article http://nej.sagepub.com/cgi/content/abstract/15/2/147?rss=1 The aim of this article is to analyse and discuss the ethically problematic conflict raised by patients with stroke who refuse nutritional treatment. In analysing this conflict, the focus is on four different aspects: (1) Is nutritional treatment biologically necessary? (2) If necessary, is the reason for refusal a functional disability, lack of appetite or motivation, misunderstanding of the situation or a genuine conflict of values? (3) If the latter, what values are involved in the conflict? (4) How should we deal with the different kinds of refusal of nutritional treatment? We argue that patients' autonomy should be respected as far as possible, while also considering that those who have suffered a stroke might re-evaluate their life as a result of a beneficial prognosis. However, if patients persist with their refusal, health care professionals should force nutritional treatment only when it is clear that the patients will re-evaluate their future life.

]]> 2008-02-13 info:doi/10.1177/0969733007086013 2 15 159 2008-03-01 147 Article http://nej.sagepub.com/cgi/content/abstract/15/2/160?rss=1 The aim of this study was to describe nurses' conceptions of decision making with regard to life-sustaining treatment for dialysis patients. Semistructured interviews were conducted with 13 nurses caring for such patients at three hospitals. The interview material was subjected to qualitative content analysis. The nurses saw decision making as being characterized by uncertainty and by lack of communication and collaboration among all concerned. They described different ways of handling decision making, as well as insufficiency of physician—nurse collaboration, lack of confidence in physicians, hindrances to patient participation, and ambivalence about the role of patients' next of kin. Future research should test models for facilitating communication and decision making so that decisions will emerge from collaboration of all concerned. Nurses' role in decision making also needs to be discussed.

]]> 2008-02-13 info:doi/10.1177/0969733007086014 2 15 173 2008-03-01 160 Article http://nej.sagepub.com/cgi/content/abstract/15/2/174?rss=1 Nursing professionals are in key positions to support end-of-life decisions and to advocate for patients and families across all health care settings. Advocacy has been identified as the common thread of quality end-of-life nursing care. The purpose of this comparative descriptive study was to reveal acute care nurses' perceptions of advocacy behaviors in end-of-life nursing practice. The 317 participating nurses reported frequent contact with dying patients despite modest exposure to end-of-life education. This study did not confirm an overall difference in advocacy behaviors among novice, experienced and expert nurses; however, it offered insight into the supports and barriers nurses at different skill levels experienced in their practice of advocacy.

]]> 2008-02-13 info:doi/10.1177/0969733007086015 2 15 185 2008-03-01 174 Article http://nej.sagepub.com/cgi/content/abstract/15/2/186?rss=1 This article presents the attitudes of nurses towards three issues concerning their role in euthanasia and physician-assisted suicide. A questionnaire survey was conducted with 1509 nurses who were employed in hospitals, home care organizations and nursing homes. The study was conducted in the Netherlands between January 2001 and August 2004. The results show that less than half (45%) of nurses would be willing to serve on committees reviewing cases of euthanasia and physician-assisted suicide. More than half of the nurses (58.2%) found it too far-reaching to oblige physicians to consult a nurse in the decision-making process. The majority of the nurses stated that preparing euthanatics (62.9%) and inserting an infusion needle to administer the euthanatics (54.1%) should not be accepted as nursing tasks. The findings are discussed in the context of common practices and policies in the Netherlands, and a recommendation is made not to include these three issues in new regulations on the role of nurses in euthanasia and physician-assisted suicide.

]]> 2008-02-13 info:doi/10.1177/0969733007086016 2 15 198 2008-03-01 186 Article http://nej.sagepub.com/cgi/content/abstract/15/2/199?rss=1 Qualitative research poses ethical issues and challenges unique to the study of human beings. In developing the interpersonal relationship that is critical to qualitative research, investigator and participant engage in a dialogic process that often evokes stories and memories that are remembered and reconstituted in ways that otherwise would not occur. Ethical issues are raised when this relationship not only provides qualitative research data, but also leads to some degree of therapeutic interaction for the participant. The purpose of this article is to examine some of the controversies inherent in the researcher's dilemma when this occurs, set within the context of a nursing caring theory (Swanson), and the International Council of Nurses Code of ethics for nurses, which provides guidance on global nursing practice.

]]> 2008-02-13 info:doi/10.1177/0969733007086018 2 15 207 2008-03-01 199 Article http://nej.sagepub.com/cgi/content/abstract/15/2/208?rss=1 Little is known about study co-ordinators of gene therapy clinical trials. The purposes of this study were to: (1) describe characteristics of co-ordinators of gene therapy (transfer) clinical trials; (2) assess differences between nurse and non-nurse study co-ordinators; and (3) identify factors indicative of study co-ordinators' role preparation that could affect their role performance. This exploratory correlational study employed a convenience sample of 118 co-ordinators in the USA (55 participants; 47% response rate). The researcher created the Study Coordinator Role Preparedness and Performance Survey to assess factors or correlates of study co-ordinator performance. Analysis of variance was used to compare nurses and non-nurses, and men versus women on their perceived preparedness, perceived quality of orientation, and satisfaction with educational opportunities. The findings contribute to knowledge by identifying present inadequacies in the training of study co-ordinators and in recognizing the need for more effective provision of orientation and continuing education with respect to ethical issues, knowledge of genetic science, and potential research integrity challenges.

]]> 2008-02-13 info:doi/10.1177/0969733007086019 2 15 221 2008-03-01 208 Article http://nej.sagepub.com/cgi/content/abstract/15/2/222?rss=1 The aim of this study was to assess the attitudes of Turkish pregnant women and antenatal health care providers towards prenatal HIV testing. A self-administered questionnaire was used. The relationships between the different groups' knowledge and attitudes were analysed by using the chi-squared statistic. A total of 494 pregnant women and 181 care providers participated. Forty-four per cent of the pregnant women thought that prenatal HIV testing should be mandatory, and 84% of the health care providers thought it should be performed routinely or be mandatory. The majority of the pregnant women (74%) and half of the care providers agreed that the test results should be disclosed first to the pregnant woman. The study results also revealed that most of the prenatal care providers would not protect pregnant women's autonomy and privacy, contrary to the pregnant women's own preferences. It is essential to establish national prenatal HIV testing policies in order to prevent unethical practices and ensure satisfaction for pregnant women and health care providers.

]]> 2008-02-13 info:doi/10.1177/0969733007086020 2 15 233 2008-03-01 222 Article http://nej.sagepub.com/cgi/content/abstract/15/2/234?rss=1 The aim of this article is to take relational ethics concepts and apply them to the context of application to research ethics committees for approval to carry out research. The process of a multinational qualitative research application is described. The article suggests that a relational ethics approach can address two issues: how qualitative proposals are interpreted by research ethics committees and how this safeguards potentially vulnerable respondents. In relational terms, the governance of a research project may be enhanced by shared ownership and willingness to engage in mutual dialogue. This challenges both researchers and research ethics committees to reframe their understanding of roles and functions in the assessment of research protocols, particularly those of a qualitative nature and those that address end-of-life issues.

]]> 2008-02-13 info:doi/10.1177/0969733007086021 2 15 242 2008-03-01 234 Article http://nej.sagepub.com/cgi/content/abstract/15/2/243?rss=1 Nurse leaders, including clinical nurse educators, who exercise stewardship at the point of service, may facilitate practising nurses' articulation of their shared value priorities, including respect for persons' dignity and self-determination, as well as equity and fairness. A steward preserves and promotes what is intrinsically valuable in an experience. Theories of virtue ethics and discourse ethics supply contexts for clinical nurse educators to clarify how they may facilitate nurses' articulation of their shared value priorities through particularism and universalism, as well as how they may safeguard nurses' self-interpretation and discursive reasoning. Together, clinical nurse educators and nurses may contribute to management decisions that affect the point of service, and thus the health care organization.

]]> 2008-02-13 info:doi/10.1177/0969733007086022 2 15 253 2008-03-01 243 Article http://nej.sagepub.com/cgi/content/abstract/15/2/254?rss=1 Moral distress has received much attention in the international nursing literature in recent years. In this article, we describe the evolution of the concept of moral distress among nursing theorists from its initial delineation by the philosopher Jameton to its subsequent deployment as an umbrella concept describing the impact of moral constraints on health professionals and the patients for whom they care. The article raises worries about the way in which the concept of moral distress has been portrayed in some nursing research and expresses concern about the fact that research, so far, has been largely confined to determining the prevalence of experiences of moral distress among nurses. We conclude by proposing a reconsideration, possible reconstruction and multidisciplinary approach to understanding the experiences of all health professionals who have to make difficult moral judgements and decisions in complex situations.

]]> 2008-02-13 info:doi/10.1177/0969733007086023 2 15 262 2008-03-01 254 Article http://nej.sagepub.com/cgi/content/abstract/15/2/263?rss=1 The current debate that surrounds the issue of patient rights and the transformation of health care, social insurance, and reimbursement systems has put the topic of patient responsibility on both the public and health care sectors' agenda. This climate of debate and transition provides an ideal time to rethink patient responsibilities, together with their underlying rationale, and to determine if they are properly represented when being called `patient' responsibilities. In this article we analyze the various types of patient responsibilities, identify the underlying motivations behind their creation, and conclude upon their sensibleness and merit. The range of patient responsibilities that have been proposed and implemented can be reclassified and placed into one of four groups, which are more accurate descriptors of the nature of these responsibilities. We suggest that, within the framework of a free-market system, where health care services are provided based on the ability to pay for them, none of these can properly be justified as a patient responsibility.

]]> 2008-02-13 info:doi/10.1177/0969733007086024 2 15 273 2008-03-01 263 Article http://nej.sagepub.com/cgi/reprint/15/2/274?rss=1 2008-02-13 info:doi/10.1177/0969733007086025 2 15 275 2008-03-01 274 Article http://nej.sagepub.com/cgi/reprint/15/2/276?rss=1 2008-02-13 info:doi/10.1177/0969733007086030 2 15 278 2008-03-01 276 Article http://nej.sagepub.com/cgi/reprint/15/2/279?rss=1 2008-02-13 info:doi/10.1177/0969733007086026 2 15 279 2008-03-01 279 Article http://nej.sagepub.com/cgi/reprint/15/2/279-a?rss=1 2008-02-13 info:doi/10.1177/09697330080150021502 2 15 280 2008-03-01 279 Article http://nej.sagepub.com/cgi/reprint/15/2/280?rss=1 2008-02-13 info:doi/10.1177/09697330080150021503 2 15 281 2008-03-01 280 Article http://nej.sagepub.com/cgi/reprint/15/2/282?rss=1 2008-02-13 info:doi/10.1177/0969733007086029 2 15 283 2008-03-01 282 Article