The International Council of Nurses [ICN] Code for Nurses clearly states that the registered nurse's first obligation is to the patient (ICN, 1973). But, in the clinical setting, multiple loyalties or obligations to the patient, family, physician, employing agency, professional standards, and personal ethical beliefs may conflict. Given the diversity of obligation in nursing practice and the ever expanding array of life sustaining technologies and techniques, a problem arises for nurses when they attempt to employ clinical guidelines offered by the ICN Code. Therefore, in order to ascertain how nurses uphold patient autonomy when responding to conflicts in the empirical setting and to delineate the patterns of reasoning which contribute to the actual response as well as to the preferred response, a qualitative grounded theory methodology was selected. This exploratory approach provided evidence that when conflict occurs, perceptions of relevancy on both a cognitive and affective level, influence the nurses' response. Often nurses with apparently equal cognitive capabilities on a moral developmental level perceived conflict of loyalty situations in vastly different ways and thereby responded with a range of behavior that went from exemplary care, which supported patient autonomy, to unsafe care, which completely denied patients their autonomy. An inductively derived substantive theory outlines this variance in care. The manner in which patient autonomy is upheld in multiple loyalty conflicts can be expressed on a three dimensional categorical basis with perceptions of imposed, bounded and volitional relevance conjoined with three levels of cognitive moral development, including both descriptive and normative explanations of conflict resolution. Principles and their supporting rules for nursing action derived from each category emphasize the little researched but complex relationship between moral cognitions, perceptions and affective valuing. / Applied Science, Faculty of / Nursing, School of / Graduate

This study describes nurses' ethical perspectives on nursing dying patients in a critical care setting, as well as nurses' responses to their perspectives. The design involved a phenomenological approach, with unstructured interviews with eight critical care nurses used to generate data. The results indicated that nurses' ethical perspectives centered around a theme of senselessness; a senseless decision-making process, the experiences of patients and family members as senseless, and nurses' activities as senseless. Senselessness illustrated the multiple ethical dilemmas inherent in nurses' experiences. Nurses' ethical perspectives also involved their attempts to cope with senselessness by finding new meanings through shifting focus to patient comfort, support of the family, and to nurses' personal philosophies. The situational context of nurses' perspectives was explored in terms of influences on their perspectives. This study supports other recent nursing research identifying prolongation of the process of dying as a significant ethical problem engendering moral distress. / Applied Science, Faculty of / Nursing, School of / Graduate

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Thesis advisor: Pamela J. Grace / Background: As established in professional codes of ethics, critical care nurses must be equipped to provide good (ethical) patient care. This requires ethical awareness, which involves recognizing the ethical implications of all nursing actions (ranging from the mundane to the dilemmatic). Ethical awareness is imperative in successfully addressing patient needs, however, evidence suggests that the ethical import of everyday issues may often go unnoticed by nurses in practice. Assessing nurses’ ethical awareness is a necessary first step in preparing nurses to identify and manage ethical issues in the highly dynamic critical care environment. Purpose: To use Rasch principles to develop a psychometrically sound instrument to assess the nature and extent of critical care nurses’ ethical awareness in the context of everyday nursing practice, and to assess the success of scale development using a Rasch model. Method: An item bank representing nursing actions was developed (33 items). Content validity testing with nursing ethics experts (n = 5) was performed (CVI-I = 1). Eighteen items were selected for face validity testing with graduate nursing students (n = 7). After revisions, two full-scale pilot administrations were performed to run item analyses. Sample: Critical care nurses (n = 116) at a large academic teaching hospital in New England. Results: Pilot test analyses suggest sufficient item invariance across samples and sufficient construct validity. Final analyses demonstrate a progression of items uniformly along a hierarchical continuum; items that match respondent ability levels; response categories that are sufficiently used; a Principle Components Analysis demonstrating randomness of residuals, and adequate internal consistency (Cronbach’s α = 0.83). Mean ethical awareness scores were in the low/moderate range (M = 34.9/54; logit = -0.21). Conclusion: The results of this study suggest the Ethical Awareness Scale (EAS) is a psychometrically sound, reliable, and valid measure of ethical awareness in critical care nurses. / Thesis (PhD) — Boston College, 2017. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

The central concern of this thesis is the diversity of the discourses of caring within nursing knowledge. Drawing on three of the tools of ‘Foucauldian archaeology’, namely the statement, discursive formation and discourse, ‘An archive of Caring for Nursing’ is identified. At least three discourses comprise this archive. These are ‘caring as being’, ‘caring as doing’, ‘caring as knowing’. Each discourse is described in the thesis and critically analysed for influences on contemporary nursing knowledge, education, theory, management and practice. Practice exemplars are utilised to elaborate the conflict between the author’s discursive position and the positions of other nurse practitioners and educators. The thesis contributes to nursing knowledge, nurse education and practice. How nurses are positioned within discourses of caring and how they resist within these discourses, is especially significant for nursing’s future. / Doctor of Philosophy (PhD)

Western nursing has been deeply influenced by Christianity and more latterly by the Nightingale ideal of the good nurse. Both views have, as their foundation, the belief that there is an objectively knowable good way to live. This belief presents problems to the modern nurse and has, in large part, been rejected. However, the rejection of this objective moral foundation for nursing has resulted in a crisis of confidence about the best way to articulate what it is to be a good nurse. Two new ways have emerged in recent times. A scientific approach to nursing has elevated the work of nursing to increasingly complex levels and resulted in significantly improved health outcomes for patients. This scientific approach to nursing has manifested itself in two ways. It has resulted in the development of theories of nursing based on psychological concepts. Parallel to this approach has been the tendency for nursing itself to become increasingly scientific and nurses in turn to be technologists. It was thought that nursing that was increasingly shaped in scientific terms would achieve professional status because it presented a scientifically verifiable knowledge base. At the same time, however, it has resulted in an understanding of what counts as being a good nurse being reduced to the nurse’s ability to perform tasks to a high level of clinical precision. Alternatively, nursing as a care-based activity has made a caring attitude the moral centre point of nursing. On this view objective standards of practice are regarded as secondary to the emotional care that the nurse brings to the patient. This belief arose in part because notions of the objectivity of science were challenged as ideological rather than the dispassionate form of knowledge that scientists claimed. It was fostered by the emergence and dominance of phenomenology and the influence of the feminist care ethic. There was also some anxiety about what had been lost in nursing by the embrace of science. In addition, the care ethic seemed to promise the possibility of defining nursing in its own terms in order to make nursing a distinct professional body. However, the demands of an ethic of care have proven elusive and, in the minds of some, unattainable. Given these criticisms of both these ways of thinking about nursing it is proposed that nursing think of itself as a virtues-based activity. Virtues theory incorporates within it the strengths of the two formerly mentioned ways of describing nursing without being subject to the limitations of each. Virtues such as love friendliness, compassion , courage and conscientiousness and the intellectual virtue of prudence or practical wisdom enable nurses to realise that goal in their practice. In this thesis virtue theory will be analysed and applied to nursing in the following way. Some Aristotelian concepts will be identified and their application t professional ethics by contemporary virtue theorists will be discussed. This involves and explication of some virtues that enhance shared conceptions of the practice of nursing. The significance of the good nurse in the shaping of good nursing practice will be considered alongside a reflection on the place of moral luck in nursing practice. It is argued that when nurses think of themselves as participating in a tradition of health care they find meaning in their work, Finally an understanding of nursing as a virtue-based activity clarifies good practice in such a way that nurses are able to elicit from it the qualities needed for its good practice.

The aim of this thesis is to propose and defend a maxim to serve as a foundation and guideline for professional ethics in nursing. The thesis is informed by philosophical ethics and by first-hand knowledge of professional nursing practice.

Murder is not a phenomenon that sits comfortably with the typical image of nurses and yet the number of cases of nurses accused and convicted of murdering patients is mounting. The nursing literature is quiet on the subject and therefore what is generally known on the topic predominantly comes from the media. An analysis of this seemingly unfathomable phenomenon is required to re-consider the problem and understand from new perspectives how and why this is happening. The aim of the study is to provide information for health professionals and organisations that will help them work together to recognise situations in which murder by nurses can occur. The research question is: How do the various discourses surrounding murder committed by nurses on patients in the course of their work shape the definition and treatment of these crimes? A discursive analysis of texts guided by a number of discourse theorists is undertaken to reveal the social construction of murder of patients by nurses. Texts related to the media and professional reporting of over 50 cases of registered nurses, enrolled and licensed nurses and assistants were retrieved from searches of Factiva, CINAHL and MEDLINE between 1980 to 2006. The software program JBI-NOTARI® (Joanna Briggs Institute, 2003b) houses the texts and facilitated analysis. Discursive constructions are reported in four findings chapters and include: the profile of murderous nurses; types of murders; contexts in which murder takes place; factors that aid detection and apprehension; legal processes that guide charges, convictions and punishment; and finally the reactions of the public, the profession, the regulators and the families. The murder of patients by nurses is construed as a combination of extraordinary nurses, extraordinary deeds in ordinary contexts. While members of the nursing profession may not be held accountable for the actions of aberrant nurses who murder there is a responsibility to understand how hospitals and units form crucibles in which murder can take place. The recommendations from this study relate to both practice and research. Practitioners are recommended to critically reflect on structures and processes. / Thesis(Ph.D.)-- School of Population Health and Clinical Practice, 2008