Advance care planning involves understanding and sharing values and goals to ensure people with serious illnesses receive treatment that is consistent with their preferences. With the growing treatment options available to patients living with advanced heart failure, advance care planning is regarded as a means of preserving individual autonomy. Despite significant public awareness campaigns, research, and interventions to increase advance care planning, it remains under-utilized in heart failure care. The aim of this research was to gain an understanding of how patients with heart failure understand and express their autonomy through the process of advance care planning. Critical qualitative multiple-case study methodology was used. Cases were constructed using data from 19 interviews with seven patients, eight caregivers, and nine healthcare providers from across two institutions. Constructions of autonomy were developed using within- and across-case analysis guided by a relational conception of autonomy based in feminist ethics. There were three key findings: (1) advance care planning is understood as external to treatment decision-making within the current biomedical landscape; (2) the experience of autonomy in advanced heart failure is incongruent with the dominant individualistic approach; and (3) advance care planning is influenced by interpersonal relationships and responsibilities as well as interpersonal and social power dynamics. Although advance care planning is considered a practice that preserves individual autonomy, interpersonal, institutional, and societal level relationships were all heavily influential in this practice. Future research should consider the advancement of advance care planning, and the enactment of autonomy, using a relational framework that acknowledges autonomy is shaped by institutional, social, and interpersonal relationships.

Patient advocacy must be understood as an ethical component of nursing practice that involves respecting and defending patients' rights and autonomy. During the COVID-19 pandemic, the vulnerability of patients in intensive care units (ICUs) increased requiring that nurses advocate for those patients more than ever in a context in which changes in daily nursing practices of care imposed by the pandemic deeply impacted nurses' advocacy. In this study, we examined ICU nurses' patient advocacy during the pandemic, using feminist ethics as a theoretical lens. Twenty-five ICU nurses from Brazil participated in individual interviews. Our findings reflect that advocacy is a moral component of nursing identity. This moral identity represents the identity of nurses as a profession as it represents their values and responsibilities which are social in nature. Although the pandemic challenged nurses' advocacy practices these professionals had an important role to give voice to patients and to preserve their autonomy and dignity, strengthening patient-centered care.

Bereavement scholarship predominantly examines psychological aspects of grief, which neglects the role of social, economic, and political factors that shape the space to accommodate these experiences. Responding to calls for enhancing bereavement care, this research explores bereavement accommodation for workers in precarious employment in Ontario, Canada. Drawing on critical qualitative research and feminist ethics, this study employed in-depth interviews to generate knowledge on the everyday experiences of bereaved workers in precarious employment. Participants expressed they were uninformed and unprepared for grief and practical bereavement labor, and that navigating the current context created tension, stress, exhaustion, isolation, and stigma. We argue the systemic neglect of bereavement is driven by socio-political forces that devalue relationality, stigmatize emotions, and render bereavement an individual responsibility. This research informs broad recommendations, including enhancing grief literacy, establishing safeguards for precarious workers, and creating more responsive care pathways and strategies for addressing individual and collective grief.

Suffering is an elusive aspect of healthcare, erroneously assumed to be located solely within the patient in the clinical encounter—an assumption that fails to acknowledge the pervasiveness of suffering endured by the physician. This flawed perception is morally problematic in the context of treating contested invisible disabilities (CIDs), which are often associated with medical ambiguity and uncertainty. In this paper, we argue for a relational reconceptualization of suffering in the context of CID to promote more effective care and improved physician-patient relationships. We propose, through the lens of an ethics of care, that a relational ontology of suffering makes salient certain aspects of patient-physician relationships that co-produce suffering, such as professional incompetence, empathetic distress, and epistemic and hermeneutic injustice, rendering the experience of having and treating a CID more visible. We then discuss the important implications of this understanding for this invisibly disabled identity and the therapeutic alliance between physician and patient and explore the potential of narrative-based medicine to better equip physicians with the knowledge, guidance, and skill to fulfil their ethical responsibility to care for and respond to not only the suffering of this population, but their own suffering as well.

Introduction: Healthcare delivery is shaped by policy, which responds to contemporary circumstances. As an example of this, the COVID-19 pandemic significantly disrupted healthcare delivery in Canada, including the work of primary care professionals, whose experiences have received less attention. Accordingly, this study investigates the experiences of primary teams during the COVID-19 pandemic, with particular attention paid to experiences of moral distress as precipitated by policy changes. Methods: Qualitative case study methodology was employed to collect data across two distinct cases: primary care practices, located in Ontario (1) and Alberta (1), Canada. Semi-structured interviews were conducted with 25 healthcare and administrative professionals, and review of public policy and clinic-associated documents aided in understanding policy context. Data analysis was concurrent with data collection and generated within- and across-case themes. Results: Participants in both cases recognized the importance of infection control policies but described constraints relating to forgoing preventative care and disruption of care continuity. Participants described the cumulative effect of ethical tensions arising from constraints in providing care related to the core values of primary care. While most participants did not mention moral distress explicitly, many described ethically challenging situations that align with core features of the phenomenon. Conclusions: Primary care professionals felt that pandemic policy changes affected them leaving them unable to provide the type of care they felt morally obligated to provide. They experienced a cumulative sense of unresolved ethical tension that grew over time, as the pandemic-induced policies disrupted their core practice of continuous, preventative, and relationship-centered care.

Background: Since the beginning of the COVID-19 pandemic, moral distress among healthcare workers in the Intensive Care Unit (ICU) has garnered both media and academic attention. Moral distress has been theorized as occurring when individuals are constrained from doing what they perceive as morally right. This study sought to empirically examine the lived experiences of moral distress among clinical and administrative healthcare professionals in a sample of Canadian ICUs during the COVID-19 pandemic. Methods: Qualitative case study methodology was used as the overarching approach, collecting and comparing data from two distinct cases: one ICU in Ontario and one in Alberta. Data collection involved two primary sources: semi-structured interviews with staff and document review of institutional and government directives to provide contextual data. Data analysis commenced concurrently with data collection, and generated within- and across-case themes, as well as allowed descriptive accounts of moral distress. Results: Thirty-six healthcare workers across two sites were interviewed. Participants described three primary categories of constraints leading to moral distress. These were: 1) The rapidity and opaqueness of policy development, specifically pertaining to 2) the implementation of family visitation and treatment triage decisions, and 3) resource shortages, which reduced patient interactions, shifted professional responsibilities. Each of these constraints yielded circumstances and forced decisions that were perceived as morally wrong because they compromised care quality and outcomes. Conclusions: While sharing similarities with the growing literature on moral distress in the context of the COVID-19 pandemic, this study reveals new insights on how provincial and institutional policy has direct bearing on experiences of moral distress. Policies and circumstances forced ICU staff to choose between actions they considered the most right and the least wrong. Understanding these specific policy-driven constraints highlights the need for healthcare systems and processes that mitigate moral distress and sustain our health workforce.

Abstract This chapter examines the concept of moral community, arguing that the characteristics of a moral community can be well articulated using the theoretical representation of morality in feminist ethics. The authors reflect on the history of the concept in nursing and medicine that draws attention to the importance of relationships in delivering care in increasingly complex environments that function best when people are accountable to each other in fulfilling their responsibilities. Next, they examine empirical studies that demonstrate the role of moral communities in preventing and diminishing the moral concerns of nurses by fostering positive identities, repairing damaged identities, and supporting moral agency. Particular attention to the feminist concept of situated knowing is explored to add understanding to how the perspectives of people are variously respected in a moral community. Ultimately, moral communicative work and institutional and structural support are essential in building and sustaining moral communities.

Despite growth in numbers of organizational antimicrobial stewardship programs, antimicrobial resistance continues to escalate. Interprofessional education and collaboration are needed to make these programs appropriately responsive to the ethically and clinically complex needs of patients at the end of life whose care plans still require antimicrobial management.

The evidence shows that COVID-19 vaccines can reduce the risks of poor pregnancy outcomes. Yet, reluctance to vaccinate remains high in pregnant populations. In this paper, we take a precision health and patient-centered approach to vaccine hesitancy. We adopted the society-to-cells vaccine hesitancy framework to identify society, community, family, individual, and physiologic factors contributing to COVID-19 vaccine hesitancy in pregnancy. Nurses are particularly well-suited to impact the factors associated with vaccine hesitancy. Because of their proximity to the patient, nurses are positioned to provide individualized, timely health information, and clinical guidelines to assist patients with decision-making related to vaccinations. Recommendations are provided to bolster nurses' engagement in precision health and patient-centered models of care to mitigate COVID-19 vaccine hesitancy in pregnancy.

BackgroundCharting is an essential component of professional nursing practice and is arguably a key element of patient safety in surgery: without proper, objective, and timely documentation, both benign and tragical errors can occur. From surgery on wrong patients to wrong limbs, to the omission of antibiotics administration, many harms can happen in the operating room. Documentation has thus served as a safeguard for patient safety, professional responsibility, and professional accountability. In this context, we were puzzled by the practices we observed with respect to charting compliance with the surgical safety checklist (SSC) during a study of surgical teams in a large, urban teaching hospital in Canada (pseudonym 'C&C').MethodsThis article leverages institutional ethnography and a subset of data from a larger study to describe and explain the social organisation of the system that monitored surgical safety compliance at C&C from the standpoint of operating room nurses. This data included fieldnotes from observations of 51 surgical cases, on-the-spot interviews with nurses, formal interviews with individuals who were involved in the design and implementation of the SSC, and open-ended questions from two rounds of survey of OR teams.FindingsWe found that the compliance form and not the SSC itself formed the basis for reporting. To meet hospital accuracy in charting goals and legislated compliance documentation reporting requirements nurses 'pre-charted' compliance with the surgical checklist. The adoption of this workaround technically violated nursing charting principles and put them in ethically untenable positions.ConclusionsDocumenting compliance of the SSC constituted a moral hazard, constrained nurses' autonomy and moral agency, and obscured poor checklist adherence. The findings highlight how local and extra local texts, technologies and relations create ethical issues, raise questions about the effectiveness of resulting data for decision-making and contribute to ongoing conversations about nursing workarounds.

Background Nurses’ demonstration of compassion is an ethical and often regulatory expectation. While research has been conducted to examine the barriers and facilitators of compassion in nurses, little is known about how nurses develop and express compassion for patients who may be blamed for their health condition. Unvaccinated COVID-19 patients are an example of such patients. Research questions How do nurses provide compassionate care for unvaccinated adults infected with COVID-19? How did the context of COVID-19 vaccination in Canada shape nurses’ relationships with unvaccinated patients? Research design A generic qualitative approach using interviews to gather data was used. Martha Nussbaum’s conceptualization of compassion and its cognitive requirements was employed to add depth to the analysis. Participants and research context Seventeen Registered Nurses, from a range of practice settings, who had cared for unvaccinated patients with COVID-19 participated. Ethical considerations Ethics approval was received, and signed informed consent was obtained. Participants who were the current students of the researchers were excluded. Findings Three themes were identified: 1) Encountering Extreme Workplace Impediments to Compassion. 2) Managing Emotions to Provide “Nonjudgmental Care.” 3) Practicing Narrative Imagination. Discussion The difficult working conditions during the pandemic impeded nurses’ capacity to be compassionate. Yet, none judged their patients’ suffering as trivial, and all provided necessary nursing care. Some initially blamed these patients for the severity of their illness and suppressed their emotions to provide what they called “nonjudgmental care.” Upon reflection, participants recognized that these patients’ life circumstances may have been barriers to vaccination which, in the end, facilitated the development of compassion. Conclusion This research has implications that go beyond that of caring for patients with COVID-19. The ideal of “nonjudgmental care” requires critical re-examination because judgments and emotions are required for compassion.

Objective: To determine timing and risk factors associated with readmission within 30 days of discharge following noncardiac surgery. Background: Hospital readmission after noncardiac surgery is costly. Data on the drivers of readmission have largely been derived from single-center studies focused on a single surgical procedure with uncertainty regarding generalizability. Methods: We undertook an international (28 centers, 14 countries) prospective cohort study of a representative sample of adults ≥45 years of age who underwent noncardiac surgery. Risk factors for readmission were assessed using Cox regression (ClinicalTrials.gov, NCT00512109). Results: Of 36,657 eligible participants, 2744 (7.5%; 95% confidence interval [CI], 7.2–7.8) were readmitted within 30 days of discharge. Rates of readmission were highest in the first 7 days after discharge and declined over the follow-up period. Multivariable analyses demonstrated that 9 baseline characteristics (eg, cancer treatment in past 6 months; adjusted hazard ratio [HR], 1.44; 95% CI, 1.30–1.59), 5 baseline laboratory and physical measures (eg, estimated glomerular filtration rate or on dialysis; HR, 1.47; 95% CI, 1.24–1.75), 7 surgery types (eg, general surgery; HR, 1.86; 95% CI, 1.61–2.16), 5 index hospitalization events (eg, stroke; HR, 2.21; 95% CI, 1.24–3.94), and 3 other factors (eg, discharge to nursing home; HR, 1.61; 95% CI, 1.33–1.95) were associated with readmission. Conclusions: Readmission following noncardiac surgery is common (1 in 13 patients). We identified perioperative risk factors associated with 30-day readmission that can help frontline clinicians identify which patients are at the highest risk of readmission and target them for preventive measures.

Conscientious objections (CO) can be disruptive in a variety of ways and may disadvantage patients and colleagues who must step-in to assume care. Nevertheless, nurses have a right and responsibility to object to participation in interventions that would seriously harm their sense of integrity. This is an ethical problem of balancing risks and responsibilities related to patient care. Here we explore the problem and propose a nonlinear framework for exploring the authenticity of a claim of CO from the perspective of the nurse and of those who must evaluate such claims. We synthesized the framework using Rest's Four Component Model of moral reasoning along with tenets of the International Council of Nursing's (ICN) Code of Ethics for Nurses and insights from relevant ethics and nursing ethics literature. The resulting framework facilitates evaluating potential consequences of a given CO for all involved. We propose that the framework can also serve as an aid for nurse educators as they prepare students for practice. Gaining clarity about the sense in which the concept of conscience provides a defensible foundation for objecting to legally, or otherwise ethically, permissible actions, in any given case is critical to arriving at an ethical and reasonable plan of action.

Background The COVID-19 pandemic has challenged the mental health of health care workers, increasing the rates of stress, moral distress (MD), and moral injury (MI). Virtual reality (VR) is a useful tool for studying MD and MI because it can effectively elicit psychophysiological responses, is customizable, and permits the controlled study of participants in real time. Objective This study aims to investigate the feasibility of using an intervention comprising a VR scenario and an educational video to examine MD among health care workers during the COVID-19 pandemic and to use our mobile app for longitudinal monitoring of stress, MD, and MI after the intervention. Methods We recruited 15 participants for a compound intervention consisting of a VR scenario followed by an educational video and a repetition of the VR scenario. The scenario portrayed a morally challenging situation related to a shortage of life-saving equipment. Physiological signals and scores of the Moral Injury Outcome Scale (MIOS) and Perceived Stress Scale (PSS) were collected. Participants underwent a debriefing session to provide their impressions of the intervention, and content analysis was performed on the sessions. Participants were also instructed to use a mobile app for 8 weeks after the intervention to monitor stress, MD, and mental health symptoms. We conducted Wilcoxon signed rank tests on the PSS and MIOS scores to investigate whether the VR scenario could induce stress and MD. We also evaluated user experience and the sense of presence after the intervention through semi–open-ended feedback and the Igroup Presence Questionnaire, respectively. Qualitative feedback was summarized and categorized to offer an experiential perspective. Results All participants completed the intervention. Mean pre- and postintervention scores were respectively 10.4 (SD 9.9) and 13.5 (SD 9.1) for the MIOS and 17.3 (SD 7.5) and 19.1 (SD 8.1) for the PSS. Statistical analyses revealed no significant pre- to postintervention difference in the MIOS and PSS scores (P=.11 and P=.22, respectively), suggesting that the experiment did not acutely induce significant levels of stress or MD. However, content analysis revealed feelings of guilt, shame, and betrayal, which relate to the experience of MD. On the basis of the Igroup Presence Questionnaire results, the VR scenario achieved an above-average degree of overall presence, spatial presence, and involvement, and slightly below-average realism. Of the 15 participants, 8 (53%) did not answer symptom surveys on the mobile app. Conclusions Our study demonstrated VR to be a feasible method to simulate morally challenging situations and elicit genuine responses associated with MD with high acceptability and tolerability. Future research could better define the efficacy of VR in examining stress, MD, and MI both acutely and in the longer term. An improved participant strategy for mobile data capture is needed for future studies. Trial Registration ClinicalTrails.gov NCT05001542; https://clinicaltrials.gov/study/NCT05001542 International Registered Report Identifier (IRRID) RR2-10.2196/32240