The establishment of effective relationships is fundamental to good nursing practice and the fulfillment of nurses’ moral responsibilities. While intrapartum nurses are uniquely placed to establish relationships that can directly influence the woman’s experience of childbirth, there has been limited investigation of the relationships, identities and values that underlie nurses’ varied approaches and responses to labouring women. The purpose of this study was to explore intrapartum nurses’ understanding of their moral responsibilities from a social-moral perspective, using Margaret Urban Walker’s “expressive-collaborative” model of morality. Interviews were conducted with fourteen registered nurses working in a birthing unit of a Canadian teaching hospital. Four themes were identified that captured nurses’ moral responsibilities, including: organizing and coordinating care, responding to the unpredictable, recognizing limits of responsibilities to others, and negotiating care with women and families. Nurses enacted their moral responsibilities to labouring women in a variety of ways depending on their personal and professional experience, the circumstances, the people involved and the context of care. A key factor influencing responses to women was the degree to which understandings and expectations related to birth were deemed to be reasonable and mutually agreed upon among nurses, physicians, women and their families. Nurses also described limits on their responsibilities to others. Their choice of response to circumstances in which practice was constrained departed from the idealized expectations and ‘expert’ practices often reflected in professional guidelines. While nurses were able to identify contextual influences that constrained their ability to maintain effective relationships with women, the influence of their own values on the care they provided was less apparent. This suggests a need to challenge normative assumptions related to care of women in childbirth, including the provision of choice and family centred care, in order to create environments that can support and sustain practices that build understanding, mutuality and trust between nurses and birthing woman. In addition, given the contested nature of childbirth and the lack of shared understandings of what constitutes ‘best’ care, there is a need to develop collaborative models of inter-professional maternity care that include the voices of women as a central component.

Thesis (M.S.)--University of Michigan, 1991.

Thesis (M.S.)--University of Michigan, 1991.

The acute care setting is designed to provide short-term care for people who require treatment for a severe episode of acute illness and exacerbations of chronic conditions. Yet, more than half of Canadians die in acute hospitals every year. Evidence shows that nurses in acute care units feel limited in their ability to provide quality end-of-life care due to a variety of factors. As a result, the needs of patients that are dying are often overlooked, which can cause them to experience a loss of identity and control, as well as suffering at the end-of-life; a unique time in one’s life trajectory marked by significant changes in personhood. Personhood is the philosophical underpinning of the frequently used concept ‘person-centered care’ – one of the fundamental ideologies of nursing and a central concept in palliative care. An interpretive description design was used to explore the following research question: What do nurses’ stories reveal about the ways in which they engage, or fail to engage, with personhood in end-of-life care in acute care units? To appreciate the culture in which participant stories were situated, a literature review of acute care culture, end-of-life care in acute care units, and the concept of personhood was conducted. Eight nurses from an acute medical-surgical ward of a tertiary care hospital in Eastern Ontario were interviewed for this study. Thematic analysis was used to analyze the data, which elucidated tensions between participants’ ability to enact ethical end-of- life care reflective of their values and the contextual constraints of working in a culture of biomedicine. Exploring these tensions provided insight on the nuances and complexities of navigating ethical end-of-life care in an acute care setting as well as implications for nursing practice, education, and research with particular attention to promoting moral communities in acute care that value personhood and biomedicine equally.

As ocorrências éticas, na assistência de enfermagem, são uma realidade com a qual não devemos nos acostumar, mas que, por outro lado, não podemos negar. O enfrentamento e especialmente a prevenção de tais ocorrências representam um constante desafio para o enfermeiro. Este estudo foi realizado com 25 Enfermeiros Responsáveis Técnicos (RTs) de Hospitais de Ensino que, em maio de 2007, compunham a lista de hospitais participantes do Sistema de Avaliação dos Hospitais de Ensino da Secretaria de Saúde do Estado de São Paulo (SAHE). Trata-se de um estudo quantiqualitativo que teve como objetivos: identificar e discorrer sobre as estratégias usadas pelos Enfermeiros Responsáveis Técnicos das referidas instituições para prevenir e/ou enfrentar as ocorrências éticas que envolvem a equipe de enfermagem; identificar a existência das Comissões de Ética de Enfermagem nestes Hospitais de Ensino e descrever as atividades que elas desenvolvem nestes locais; discorrer acerca da existência e finalidade dos registros estatísticos das ocorrências éticas de enfermagem. Além da aprovação pelo Comitê de Ética em Pesquisa da Instituição vinculada, por exigência de nove das instituições participantes do estudo, foi necessário submeter o projeto à aprovação dos Comitês locais. Os dados foram coletados no período entre julho de 2007 e março de 2008, após o estudo ter sido autorizado pelas instituições participantes e ter aquiescência dos RTs. Os resultados quantitativos foram dispostos em tabelas e discutidos com base na literatura acerca do tema, os qualitativos foram tratados segundo a Análise de Conteúdo de Bardin (2007), dispostos em categorias e unidades temáticas e posteriormente discutidos, também, com base em referências bibliográficas sobre o assunto. Os resultados mostraram que, dos 25 Hospitais de Ensino (HE), oito estão situados na cidade de São Paulo e 17 no interior do Estado; 16 são públicos e nove privados. Quanto ao porte, 14 são considerados de grande porte, cinco de porte especial, três de médio porte e três não possuem leitos de internação.Quanto ao número de profissionais, dos 17.442 profissionais dos 25 HEs, 3.349(19,20%) são enfermeiros, 3.242(18,58%), técnicos de enfermagem e 10.851(62,21%) são auxiliares de enfermagem. No que se refere às estratégias preventivas, os RTs utilizam o treinamento como primeira escolha, enquanto para o enfrentamento das ocorrências éticas, predominam as ações gerenciais, seguidas das ações da CEE. Das 25 instituições, três não tinham CEE. Dos 22 HEs que possuem CEE, 13 referem que estas foram constituídas em cumprimento às exigências legais e nove para atender às necessidades do Serviço de Enfermagem. Em relação às atividades desenvolvidas pelas CEEs, nove RTs referem a de fiscalização e 13 as educativas e de orientação. Os registros das ocorrências acontecem em 21 HEs e, na sua maioria, são feitos através de livro-ata ou relatórios. Apenas 13 RTs responderam sobre a finalidade dos registros, sendo que quatro os utilizam para direcionar a educação continuada ou ações gerenciais, e os demais procedem o arquivamento, abertura de sindicância ou encaminhamento ao Conselho Regional de Enfermagem, quando necessário. / The ethical occurrences in nursing care, are a reality that we should not get used to, but, on the other hand, we can not deny. The confrontation and especially the prevention of such occurrences represent a constant challenge to nurse personal. This study was conducted with 25 Nurse Responsible Technician (RTs) from Teaching Hospitals that in May 2007, were working in hospitals that participated in the System for the Evaluation of Teaching Hospitals, Health Department from State of Sao Paulo (SAHE). This is a quantitative and qualitative study aimed to: identify and talk about the strategies used by the Nurses Technical Responsible of those institutions to prevent and / or face the ethical occurrences involving the nursing staff, identify the existence of Nursing Ethics Committees (NEC) in Nursing Education Hospitals and describe the activities that they develop in these places; talk about the existence and purpose of statistical records of nursing ethical events. Besides the approval by the Research Ethics Committee of the Institution bound by the requirement of nine institutions participating in the study, it was necessary to bring the project to the approval of local committees. Data were collected between July 2007 and March 2008, after the study has been approved by participating institutions and acquiescence by RTs. The quantitative results were arranged on tables and discussed in the literature based on the theme, the qualitative were treated according to Content Analysis of Bardin (2007), arranged in categories and thematic units and subsequently discussed, too, based on references on the subject. The results showed that the 25 Education Hospitals (EH) under study, eight are located in Sao Paulo city (capital) and 17 in Sao Paulo state, 16 are public and nine private. Regarding size, 14 are considered large-scale, five are especial size, three mid-size and three does not have beds for internment. Referring to the number of professionals the 17,442 professionals from the 25 EHs, 3,349 (19.20%) are nurses , 3,242 (18.58%), nursing technicians and 10,851 (62.21%) are auxiliary nurses. With regard to preventive strategies, (RTs) use the training as the first choice while the confronting of ethical events, dominate the management actions, followed by EEC actins. From the 25 institutions, three had no NEC. From 22 HEs with NEC, 13 stated that they were formed in compliance with legal requirements and nine to meet the needs of the Nursing Department. In relation to activities undertaken by NECs (CEE), nine RTs refer to the supervisory and 13 to the education and guidance. The records of occurrences happen in 21 EHs and, mostly, are made through minutes-book or reports. Only 13 RTs responded on the purpose of the records, four of which use them to direct the continuing education or managerial actions, and the others do the filling, inquiry opening or the guiding to the Regional Council of Nursing, when necessary.

nÃo hà / A prÃtica de cuidado Ãtico de Enfermagem no Ãmbito dos serviÃos de saÃde, especificamente nos hospitais pÃblicos de ensino, se insere como parte do trabalho coletivo na Ãrea de saÃde, incorporando aspectos tÃcnico, gerencial, pedagÃgico, social e polÃtico. A dimensÃo Ãtica da alteridade do cuidado, neste cenÃrio laboral, assume a configuraÃÃo de uma atitude de respeito e acolhimento do outro, ensejando a continua reflexÃo e mudanÃa de atitude dos profissionais de Enfermagem. O objetivo deste estudo à compreender a concepÃÃo Ãtica do cuidado na experiÃncia cotidiana de Enfermagem no hospital pÃblico universitÃrio, com discussÃo Ãtica da alteridade radical em Emmanuel LÃvinas. De carÃter descritivo, este estudo se fundamenta na fenomenologia HermenÃutica, com abordagem qualitativa. A apreensÃo dos dados empÃricos se concretizou junto a nove enfermeiros do quadro funcional do hospital, com a utilizaÃÃo da tÃcnica de entrevista individual. A anÃlise dos depoimentos evidenciou trÃs eixos temÃticos: cuidado, Ãtica e alteridade de Enfermagem. Sob tais dimensÃes, os dados analisados permitiram identificar a importÃncia da Ãtica da alteridade no cuidado de Enfermagem, a busca da organizaÃÃo do processo de cuidar e da gestÃo, o aperfeiÃoamento profissional, a interdisciplinaridade das aÃÃes mediante a mobilizaÃÃo e articulaÃÃo de saberes, o cuidado responsÃvel e Ãtico, a atitude de entender a importÃncia da qualidade assistencial, o compromisso com a subjetividade do cuidado, ressaltados pelos entrevistados. Estes profissionais, todavia, convivem, atualmente, com as contradiÃÃes inerentes ao seu processo de trabalho, acentuando o modelo assistencial que persiste em transitar entre o modelo funcional e integral, nos moldes curativista e hospitalocÃntrico. O modelo a gestÃo imprime, ainda hoje, as caracterÃsticas do trabalho mecanicista e fragmentado; a multidisciplinaridade e sua relaÃÃo direta com a hierarquizaÃÃo do cuidado, em detrimento da interdisciplinaridade; o sofrimento ocupacional derivado das condiÃÃes laborais inadequadas; deficit progressivo da forÃa de trabalho e absenteÃsmo crescente; e mudanÃa atual da estrutura organizacional, no que concorrem para a tensÃo entre o cuidar e gerenciar. Em decorrÃncia deste cenÃrio, à possÃvel concluir que a Enfermagem resiste, de forma propositiva, a estes desafios, revelando acentuado indÃcio Ãtico em relaÃÃo à alteridade do cuidado. Esta tendÃncia poderà expressar a reflexÃo para a reinvenÃÃo da prÃtica social do cuidar, transcendendo a clÃssica atitude do cuidado parcelar para a dimensÃo da alteridade do cuidado Ãtico. / The practice of ethical Nursing care within health services, particularly in public hospitals of Education, comes as part of collective work in health, incorporating technical, managerial, educational, social and political. The ethical dimension of alterity of care in this work scene, assumes the configuration of an attitude of respect and welcome the other, and promotes a continous refletction and changing of attitude of nursing professionals. The aim of this study is to understand the design ethic of care in the daily experience of nursing in the University Public Hospital, with ethical discussion of radical alterity in Emmanuel LÃvinas. Descriptive in nature, this study is based on the Hermeneutic-phenomenology, with a qualitative approach. The seizure of the empirical data was achieved with nine nurses of the hospital staff, using the technique of individual interview. The analysis revealed evidence of three areas: care, ethics and otherness of Nursing. Under such dimensions, the data analysis allowed us to identify the importance of ethics of alterity in nursing care, the search for the organization of the care and management, the training, the interdisciplinarity of the shares through the mobilization and articulation of knowledge, the ethical and responsible care, the attitude of understanding the importance of quality care, the commitment to the subjectivity of care, highlighted by the interviewees. However, these workers live, now, with the contradictions inherent in the process of their work, emphasizing the care model that persists in transit between the model and fully functional in form and curative hospital. The management model prints, even today, the characteristics of mechanistic and fragmented work, the multidisciplinary and its relationship with the hierarchy of care, rather than interdisciplinarity; the suffering occupational derivative inadequate working conditions; progressive deficit of the workforce and increased absenteeism, and change the current organizational structure to support the tension between the handle and manage. Because of this scenario, it can be concluded that the Nursing resist, so purposeful, to these challenges, with strong evidence on ethical alterity of care. This trend can express the reflection for the reinvention of the social practice of care, beyond the classical approach of partial care for the size of alterity ethics of care

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M.Cur. / Please refer to full text to view abstract

Please read the abstract in the section 00front of this document / Thesis (DPhil)--University of Pretoria, 2009. / Nursing Science / unrestricted

Background: Nurses working in intensive care units are at high risk for experiencing moral distress, a response to an ethical event, in which a nurse recognizes or partakes in an action that does not align with their values. In response, nurses may experience negative health effects, which drives attrition. This can negatively impact patient care and the stability of healthcare organizations. There is a scarcity of high-quality and effective organizational interventions to mitigate moral distress, and even lesser work has been done to understand nurses’ practice-based needs to ameliorate moral distress. New conditions of moral distress in the context of COVID-19 have increased the relevance of these shortcomings. Aim: The purpose of this study was to learn about intensive care unit nurses’ responses to moral distress experienced in their professional practice during the COVID-19 pandemic. Methods: This interpretive descriptive study explored the experiences of 40 intensive care unit nurses, who self-reported experiencing moral distress in their professional practice during the COVID-19 pandemic (March 2020 – Sept 2021). Data generation included a demographic questionnaire, including the Measure of Moral Distress - Healthcare Professionals survey, and one-to-one semi-structured virtual interviews. The categorization and synthesis of the data was guided by methods of reflexive thematic analysis and rapid qualitative analysis. Results: Findings indicated that nurses regularly navigated pre-existing and novel ethical events in practice, which were exacerbated in the context of the COVID-19 pandemic. In response, they often experienced moral distress under the complex interplay of two overarching and broad conditions: (1) when nurses’ voices were not heard; and (2) when patients received substandard levels of care, that was not patient-centered, pain free, or that did not align standards of care. Moral distress experienced by nurses resulted in negative outcomes across serval health domains, that drove feelings of burnout and attrition. To cope, nurses engaged in patterns of action, avoidance, and acquiesce. Finally, they made recommendations for mitigative interventions rooted in their desire to be heard, in efforts to optimize patient care and nurse well-being. Conclusion: Intensive care unit nurses’ voices need to be amplified and valued, in the context of various healthcare organizations (e.g., practice, research, education and polity), to mitigate moral distress and the associated negative outcomes. / Thesis / Master of Health Sciences (MSc)