Nursing Ethics

The decision whether to initiate cardiopulmonary resuscitation may sometimes be ethically complex. While studies have addressed some of these issues, along with the role of nurses in cardiopulmonary resuscitation, most have not considered the importance of nurses acting as advocates for their patients with respect to cardiopulmonary resuscitation.

To explore what the nurse’s advocacy role is in cardiopulmonary resuscitation from the perspective of patients, relatives, and health professionals in the Basque Country (Spain).

An exploratory critical qualitative study was conducted from October 2015 to March 2016. Thematic analysis was used to analyse the data.

Four discussion groups were held: one with patients and relatives (n = 8), two with nurses (n = 7 and n = 6, respectively), and one with physicians (n = 5).

Approval was obtained from the Basque Country Clinical Research Ethics Committee.

Three significant themes were identified: (a) accompanying patients during end of life in a context of medical dominance, (b) maintaining the pact of silence, and (c) yielding to legal uncertainty and concerns.

The values and beliefs of the actors involved, as well as pre-established social and institutional rules reduced nurses’ advocacy to that of intermediaries between the physician and the family within the hospital environment. On the contrary, in primary health care, nurses participated more actively within the interdisciplinary team.

This study provides key information for the improvement and empowerment for ethical nursing practice in a cardiac arrest, and provides the perspective of patients and relatives, nurses and physicians.

Nurses must balance their perceived duty to care against their perceived risk of harm to determine their willingness to report during disaster events, potentially creating an ethical dilemma and impacting patient care.

The purpose of this study was to investigate nurses’ perceived duty to care and whether there were differences in willingness to respond during disaster events based on perceived levels of duty to care.

A cross-sectional survey research design was used in this study.

Using a convenience sample with a snowball technique, data were collected from 289 nurses throughout the United States in 2017. Participants were recruited through host university websites, Facebook, and an American Nurses Association discussion board.

Institutional review board approval was obtained from the University of Texas at Tyler and the University of Arkansas.

Analysis of willingness to report to work based on levels of perceived duty to care resulted in the emergence of two groups: “lower level of perceived duty to care group” and “higher level of perceived duty to care group.” The most discriminating characteristics differentiating the groups included fear of abandonment by co-workers, reporting because it is morally the right thing to, and because of imperatives within the Nursing Code of Ethics.

The number of nurses in the lower level of perceived duty to care group causes concern. It is important for nursing management to develop strategies to advance nurses’ safety, minimize nurses’ risk, and promote nurses’ knowledge to confidently work during disaster situations.

Level of perceived duty to care affects nurses’ willingness to report to work during disasters. Primary indicators of low perceived duty to care are amenable to actionable strategies, potentially increasing nurses’ perceived duty to provide care and willingness to report to work during disasters.

The main purpose of this study was the psychometric assessment of Jacelon’s Attributed Dignity Scale among Iranian older population.

Using a standard “forward-backward” translation procedure, the original English version of Jacelon’s Attributed Dignity Scale was translated into Persian. Internal consistency of the scale was checked by the Cronbach’s α coefficient. Convergent validity of the instrument was appraised by the Social Skills Scale and General Health Questionnaire. Factor structure of the Iranian version of Jacelon’s Attributed Dignity Scale and possible interplay between its subscales were checked through recruiting a convenient sample of 300 Iranian older people and performing the confirmatory factor analysis.

The estimated Cronbach’s α and intraclass correlation coefficients for the Iranian version of Jacelon’s Attributed Dignity Scale were in the vicinity of acceptable range, that is, 0.87 and 0.93, respectively. The output of confirmatory factor analysis revealed that a four-factor model best fitted the study data (χ² = 323.49; df = 129; p < 0.001; comparative fit index = 0.913; Tucker–Lewis index = 0.901; root mean square error approximation = 0.074; standardized root mean square residual = 0.078). Rasch estimates of item difficulty ranged from –1.28 (less difficult) to 1.33 (more difficult). No significant cross-gender differences were observed regarding the Iranian version of Jacelon’s Attributed Dignity Scale’s items indicating its invariant psychometric properties for use in the Iranian men and women subgroups.

This study was approved by the Ethics Committee at the Tabriz university of medical science. Informed consent, information confidentiality, and voluntary participation were guaranteed.

The study findings were indicative of applicability of the Iranian version of Jacelon’s Attributed Dignity Scale as a reliable tool in measurement of the perceived social dignity among Iranian and probably other Persian-speaking older populations.

Maintaining dignity is one of the most important human rights. However, maintaining and promoting the dignity of nursing students as an important caregiver group has scarcely been considered. Dignity can be viewed as an abstract concept particularly in relation to the perspective of male nursing student perspective. Therefore, more investigation is required to explore the male students’ understanding of the concept of dignity.

The purpose of this study is to define and explain the concept of dignity among male nursing students in the neonatal intensive care unit.

This is a qualitative content analysis study. The data were collected through semi-structured individual interviews. The data were analyzed by conventional content analysis method.

Twenty male nursing students in public health centers in Iran were selected by targeted sampling to achieve data saturation between February 2017 and November 2017.

The findings of this study were presented in three main themes, including “extensive support,” “belief in ability,” and “participation in decision making,” and 7 sub-categories of data were extracted.

The study’s protocol was approved by the Research Ethics Committee of the Shiraz University of Medical Sciences and the ethical principles were followed throughout the study.

According to the findings of the study, male nursing students required extensive support, and their academic and practical skills required to be respected; in addition, they should be involved in decision making, because in such an environment, the dignity of these students will be maintained and promoted. Therefore, it is suggested that a cultural, professional, and institutional background in which all components of the male nursing student’s dignity are protected and emphasized should be provided.

Moral case deliberation is a form of clinical ethics support to help healthcare professionals in dealing with ethically difficult situations. There is a lack of evidence about what outcomes healthcare professionals experience in daily practice after moral case deliberations. The Euro-MCD Instrument was developed to measure outcomes, based on the literature, a Delphi panel, and content validity testing. To examine relevance of items and adequateness of domains, a field study is needed.

To describe experienced outcomes after participating in a series of moral case deliberations, both during sessions and in daily practice, and to explore correlations between items to further validate the Euro-MCD Instrument.

In Sweden, the Netherlands, and Norway, healthcare institutions that planned a series of moral case deliberations were invited. Closed responses were quantitatively analyzed. The factor structure of the instrument was tested using exploratory factor analyses.

The study was approved in Sweden by a review board. In Norway and the Netherlands, data services and review boards were informed about the study.

The Euro-MCD Instrument was completed by 443 and 247 healthcare professionals after four and eight moral case deliberations, respectively. They experienced especially outcomes related to a better collaboration with co-workers and outcomes about individual moral reflexivity and attitude, both during sessions and in daily practice. Outcomes were experienced to a higher extent during sessions than in daily practice. The factor structure revealed four domains of outcomes, which did not confirm the six Euro-MCD domains.

Field-testing the Euro-MCD Instrument showed the most frequently experienced outcomes and which outcomes correlated with each other. When revising the instrument, domains should be reconsidered, combined with theory about underlying concepts. In the future, a feasible and valid instrument will be presented to get insight into how moral case deliberation supports and improves healthcare.

Emergency care providers are frequently faces with situations in which they have to make decisions quickly in stressful situations. They face barriers to ethical decision-making and recognizing and finding solutions to these barriers helps them to make ethical decision.

The purpose of this study was to identify barriers of ethical decision-making in Iranian Emergency Medical Service personnel.

In this qualitative research, the participants (n = 15) were selected using the purposive sampling method, and the data were collected by deep and semi-structured interviews. Finally, the data are analyzed using the content analysis approach.

Permission to conduct the study was obtained from the Ethics Committee of the Shahid Beheshti University of Medical Sciences. The objectives of the study were explained to the participants and written consent was received from them. Also, participants were assured that necessary measures were taken to protect their anonymity and confidentiality.

The results of the analysis are classified in five main categories. It encompasses the following areas: perception of situation, patient-related factors, input and output imbalance, uncoordinated health system, and paradoxes.

Emergency Medical Service personnel make ethical decisions every day. It is important that prehospital personnel know how to manage those decisions properly so that clients’ moral rights are respected. Hence, by identifying the dimensions and obstacles of ethical decision-making in Emergency Medical Service personnel, it is possible to enhance the moral judgment and ethical accountability of the personnel and develop the strategies necessary for ethical decision-making in them.

Nurses and physicians in nephrology settings provide care for patients with end-stage kidney disease receiving hemodialysis treatment along a complex illness trajectory.

The aim was to explore physicians’ and nurses’ perspectives on the trajectories toward the end of life involving decisions regarding hemodialysis withdrawal for patients with end-stage kidney disease.

A qualitative research approach was used. Four mixed focus group interviews were conducted with renal physicians (5) and nurses (17) in Sweden. Qualitative content analysis was used to analyse data.

Ethical approval was obtained (Dnr 2014/304-31).

Findings illuminated multi-faceted, intertwined processes encompassing healthcare professionals, patients, and family members. The analysis resulted in four themes: Complexities of initiating end-of-life conversations, Genuine attentiveness to the patient’s decision-making process, The challenge awaiting the family members’ processes, and Negotiating different professional responsibilities. Findings showed complexities and challenges when striving to provide good, ethical care which are related to beneficence, nonmaleficence, and self-determination, and which can give rise to moral distress.

There are ethical challenges and strains in the dialysis context that healthcare professionals may not always be prepared for. Supporting healthcare professionals in not allowing complexities to hinder the patient’s possibilities for shared decision-making seems important. An open and continual communication, including family meetings, from dialysis initiation could serve to make conversations involving decisions about hemodialysis withdrawal a more natural routine, as well as build up a relationship of trust necessary for the advance care planning about the end of life. Healthcare professionals should also receive support in ethical reasoning to meet these challenges and handle potential moral distress in the dialysis context.

Generally, a person with dementia may be unable to make decisions by themselves and professionals may decide what is best for them. Unfortunately, in most cases, professionals assist a person with dementia to make decisions without clear explanation or consent. Whether a person with dementia possesses dignity in routine care is an important issue.

The purpose of this study was to explore the lived experience of the healthcare professionals in providing dignified dementia care in Taiwan.

A qualitative, hermeneutic-phenomenological approach was conducted.

Participants were enrolled by purpose sampling. Researchers performed in-depth interviews to reveal the essential ingredient of dignity within dementia care in Taiwan. A total of 20 cases were enrolled to achieve data saturation.

This study was approved by the institutional review board. Before conducting the interview, interviewees provided informed consent.

There were three themes and six categories that were addressed and constructed; within the themes, 23 Guidelines for Taiwan Dignified Dementia Care and 12 Principles for Dignified Dementia Care in Taiwan were developed.

From the data relating to dignity in dementia care, we can develop a more independent and dignified care environment to improve the quality of life of person with dementia in Taiwan.

The results indicated that dignity within dementia care was constructed by the lived experience of the healthcare professionals, as well as affected by the culture of the organizations and society at the same time.

In research on co-creation in nursing, a caring manner can be used to create opportunities whereby the patient’s quality of life can be increased in palliative home care. This can be described as an ethical cornerstone and the goal of palliative care. To promote quality of life, nurses must be sensitive to patients’ and their relatives’ needs in care encounters. Co-creation can be defined as the joint creation of vital goals for patients through the process of shared knowledge between nurses, patients and their relatives.

The aim of this study was to explore nurses’ experiences of caring encounters and co-creation in palliative home care from an ethical perspective.

A hermeneutical approach was used. The material consisted of texts from interviews with 12 nurses in a home care context. The method was inspired by thematic analysis.

Informed consent was sought from the participants regarding study participation and the storage and handling of data for research purposes.

An overall theme, a main theme and four sub-themes emerged. Through ethical sensitivity and perceptivity, nurses can balance their actions in the moment and change their nursing care actions according to the patient’s wishes through co-creation in encounters. Here the time is crucial, as the time needed is unique to each patient.

The themes together can be considered prerequisites for good palliative home care. If nurses fail to be sensitive and perceptive in encounters with dying patients, good palliative home care cannot be achieved. Ethical sensitivity and perceptiveness can also be considered a part of nurses’ ethical competence.

Patients’ dignity can be preserved through ethical sensitivity and perceptiveness, which is fundamental for good palliative care. Co-creation from patients’ perspectives should be the focus of future research.

Ethics development is one of the most important aspects of professional practice in health sciences students. Understanding factors affecting ethics development can enhance clinical and professional performance in students.

This study was conducted to explore students’ perceptions about factors affecting professional ethics development.

This study is a conventional content analysis. Data were collected through 20 semi-structured interviews and two focus group interviews (12 students) during 2017–2018. Data were analyzed concurrently with data gathering, using the conventional content analysis approach of Graneheim and Lundman.

In total, 8 students of nursing, 5 medical students, 4 students of anesthesia and 3 operating room students in individual interviews, and 12 students in two focus group interviews from one university in the south of Iran were selected through purposive sampling.

The research was approved by the Ethics Committee of one university in the south of Iran.

The findings revealed two themes: personal and background factors. Personal factors consisted of the two categories of individual motivation and tendencies and interpersonal interactions. Background factors consisted of the two categories of role and function of teachers and environmental agents.

According to the findings, both background and individual factors affect development of professional ethics in students. Understanding these factors along with reinforcement of educational planning in this field can improve healthcare services.

Development of professional nursing values is critical within registered nurse–to–bachelor of science in nursing programs to prepare nurses for increasingly complex and diverse work environments. The results of previous studies have been inconsistent, with few studies focusing on online registered nurse–to–bachelor of science in nursing programs. In addition, little is known regarding the effectiveness of the educational methods used to support advancement of professional values and ethical practice.

The object of this study was to gain an understanding of nursing students’ attitudes and beliefs about professional values at entry and exit of an online registered nurse–to–bachelor of science in nursing program that includes a standalone ethics course and integrates American Nurses Association Code of Ethics provisions throughout the curriculum.

For this one-group pretest–posttest, quasi-experimental design, longitudinal matched-pair data were gathered at program entry and exit using the Nurses Professional Values Scale–Revised.

In all, 119 students of an online registered nurse–to–bachelor of science in nursing program at a Midwest public university who completed entry and exit surveys between spring 2015 and spring 2018 were included in this study.

This study was reviewed and determined to be exempt by the university’s institutional review board.

The results showed a significant increase in total posttest scores when considering all participants. However, students who took the ethics course after the pretest demonstrated a significant increase in posttest scores, while students who took the ethics course prior to the pretest demonstrated a small increase that was not statistically significant. Significant increases were also found in the professionalism, activism, and trust factors.

This study supports previous study findings where students scored higher on caring and lower on activism and professionalism factors. The largest gains were made after completing the ethics course.

The results suggest that requiring a standalone ethics course in the registered nurse–to–bachelor of science in nursing curriculum had a positive impact on self-reported professional values.

Compassion has long been advocated as a fundamental element in nursing practice and education. However, defining and translating compassion into caring practice by nursing students who are new to the clinical practice environment as part of their educational journey remain unclear.

The aim of this study was to explore how Chinese baccalaureate nursing students define and characterize compassionate care as they participate in their clinical practice.

A descriptive qualitative study design was used involving a semi-structured in-depth interview method and qualitative content analysis. Twenty senior year baccalaureate nursing students were interviewed during their clinical practicum experience at four teaching hospitals.

Permission to conduct the study was received from the Institutional Review Boards and the participating hospitals.

Baccalaureate nursing students defined and characterized compassionate care as a union of “empathy” related to a nurse’s desire to “alleviate patients’ suffering,” “address individualized care needs,” “use therapeutic communication,” and “promote mutual benefits with patients.” Students recognized that the “practice environment” was characterized by nurse leaders’ interpersonal relations, role modeling by nurses and workloads which influenced the practice of compassionate care by nursing personnel.

Compassionate care is crucial for patients, nurses, and students in their professional development as well as the development of the nursing profession. In order to provide compassionate care, a positive practice environment promoted by hospital administrators is needed. This also includes having an adequate workforce of nurses who can role model compassionate care to students in their preceptor role while meeting the needs of their patients.

Nurses are often faced with many stressful situations in life, including personal life challenges, the nature of work that requires standing long and being focused, commitment to patient care, and dealing with patients who need help.

The aim of this study was to investigate the relationship between empathy and compassion fatigue in nurses due to the mediating role of feeling guilty and secondary traumatic stress.

This is a descriptive-correlation study.

The statistical population consisted of all the nurses in Kerman hospitals in 2017. Five hospitals were randomly selected from among the private and public hospitals in Kerman. The sample size was considered 360, but after the deletion of misleading questionnaires, the final sample of study consisted of 300 nurses.

Approval from the researcher’s university Institutional Review Board for ethical review was obtained.

The data analysis in this study was done through the path analysis method using the Amos software. The results showed the mediating role of omnipotent guilt between empathy and compassion fatigue in the nurses, the mediating role of survivor guilt between empathy and compassion fatigue in the nurses, and the mediating role of secondary traumatic stress between empathy and compassion fatigue in the nurses. Also, empathy could explain 77% of the nurses’ compassion fatigue through feelings of guilt and secondary traumatic stress.

Pathogenic empathy-based guilt and secondary traumatic stress may help explain some of the links between clinical empathy and symptoms of compassion fatigue.

Interventions and training programs targeting pathogenic empathy-based guilt and empathic secondary traumatic stress may be particularly important to help reduce compassion fatigue.

Person-centred care is often described as an ideal way of preserving vulnerable persons’ wellbeing and dignity and an essential component of quality-care delivery. However, the staff find that making the care dignified is the most challenging issue, often because of effectivity, everyday stress and overload. In the interests of making the care more person-centred, systematic intervention involving ‘one-to-one contact’ (resident – carer) was trialled for 30 min twice a week over 12 months in two units in a nursing home in Eastern Norway.

The aim of the study was to elicit healthcare staff’s experiences of implementing ‘one-to-one contact’ between residents and carers in nursing homes.

The study has a grounded-theory inspired design. Two groups of health care staff were each interviewed three times. Data were collected over an 18-month period.

The study was approved by the Data Protection Official for Research under the auspices of the Norwegian Social Science Data Services.

The core category is ‘One-to-one contact’ at a nursing home is possible, but requires open-mindedness. The core category indicates that open-mindedness is required, since it does not take much for scepticism to take over and cause reversion to habitual practices. The category Expectant but Sceptical describes staff thoughts and experiences before the implementation phase got underway. The category Positive but Undecided describes staff experiences 6 months into the intervention and after 12 months.

This study has revealed that systematic ‘one-to-one contact’ between resident and carer in nursing home is achievable, and that such a simple action might be an important step towards achieving more person-centred care as the resident is seen more as a person. However, in order to make a more person-centred and dignified approach to care constant attentiveness and awareness is required, as there were ongoing factors counteracting it.

Privacy is one of the key principles in health care and requires understanding of the cultural aspects of patients’ privacy. In Western cultures privacy is focused on the individual, however, in some non-Western cultures, privacy is linked to the collectivism of the community or religion.

The objective of this study is to describe the factors related to the realisation of privacy of Somali refugees in health care by describing the factors related to the patient, healthcare professional and interpreter.

The data were collected from Somali refugees (N = 29) using a qualitative questionnaire and were analysed by deductive content analysis based on factors related to the patient, healthcare professional and interpreter.

Ethical approval was obtained from the University of Turku, and research permissions were obtained from all participating institutions.

Factors related to the patient were as follows: privacy was realised when the patient had self-determination; was able to act according to Somali culture; had knowledge and understanding of treatment; and trusted the healthcare professional. Factors related to the healthcare professional were as follows: the healthcare professional was expected to be of the same gender as the patient, act professionally, focus on the health issues, and to have knowledge and understanding of the Somali culture. Factors related to the interpreter were as follows: the presence and Somali background of the interpreter decreased privacy; the interpreter was expected to be of the same gender as the patient; to have competence and to behave professionally.

Gender congruence, professionalism and caring attitude and common understanding between the Somali patient and Finnish provider increase the privacy of Somali patients.

Somali patients’ privacy can be improved by increasing healthcare professionals’ understanding of Somali culture, acknowledging the importance of gender concordance in relation to healthcare professionals and interpreters, and the effect of the presence of the interpreter on patients’ privacy.

Informed consent can be obtained by various methods, by various people, and with use of various types of consent forms. Persistent effort is necessary to reveal the practical realities of informed consent to improve ethical and legal standards.

To determine the ethical challenges of obtaining informed consent from surgical patients.

The present study was a descriptive cross-sectional study using two researcher-made questionnaires and a checklist for data collection. Data were collected from nursing personnel (n = 95) and surgical patients (n = 203) on the surgical wards of three university hospitals in Isfahan, Iran. Data were analyzed using descriptive statistics, Spearman’s rank correlation, Pearson’s correlation coefficient, and the t-test.

The study was approved by the Ethics Committee of Isfahan University of Medical Sciences (No: 396478).

The mean scores (maximum 100) of awareness, competency, and authority were 36.3, 67.7, and 57.6, respectively. The overall quality of the informed consent was poor (score 53.9 of 100). The higher educational level in patients was correlated with lower awareness of and less authority to give informed consent. Only 12.6% of the nurses stated that patients were given sufficient information to assure informed consent. In 89.2% of the consent forms, the risks of the treatment were mentioned. However, alternative methods and risks and advantages of rejecting the treatment were not mentioned in any of the forms.

Ethical challenges to obtaining informed consent include patients’ poor awareness of their rights, a failure to provide adequate information to patients, absence of consideration of patients’ educational level, an unclear definition of who is responsible for obtaining informed consent from the patients, time constraints, and use of unclear language and medical jargon. Constructing an ethical framework may guide nursing staff in dealing with the ethical challenges involved in obtaining informed consent.

Ethical conflict is a phenomenon that has been under study over the last three decades, especially the types moral dilemma and moral distress in the field of nursing care. However, ethical problems and their idiosyncrasies need to be further explored.

The objectives of this study were, first, to obtain a transcultural Portuguese-language adaptation and validation of the Ethical Conflict Nursing Questionnaire–Critical Care Version and, second, to analyse Portuguese critical care nurses’ level of exposure to ethical conflict and its characteristics.

A cross-cultural validation and descriptive, prospective and correlational study. The sample was made for 184 critical care nurses in 2016.

The study was authorised by Bioethics Commission of the University of Barcelona, the Associaçâo de Apoio ao Serviço de Cuidados Intensivos do Centro Hospitalar do Porto and the Sociedade Portuguesa de Enfermagem de Saúde Mental.

The Portuguese version of the Ethical Conflict Nursing Questionnaire–Critical Care Version was a valid and reliable instrument to measure exposure to conflict. Moral outrage was the most common type of conflict. The most problematic situations were the ineffectiveness of analgesic treatments, the administration of treatments considered futile and the mismanagement of resources.

Some patients are stigmatised as difficult patients by healthcare professionals. This phenomenon has great many negative consequences. The behaviours of healthcare professionals towards difficult patients are important.

To explore the behaviours of all healthcare professionals towards difficult patients.

This study was based on a cross-sectional research design using structural equation modelling.

Two hundred and fifty-four healthcare professionals were involved in the study in Turkey. ‘Participant Information Form’ and the ‘Healthcare Professionals Behaviour Assessment Questionnaire For Difficult Patient’ were used to collect data from participants.

Ethical approval was obtained from Gazi University Ethics Committee for the study. Informed consent of the participants in the study was taken and the confidentiality of the participants was ensured.

It was explored that the behaviours of healthcare professionals towards difficult patients were categorised into ethical, supportive and negative. The highest mean score was supportive behaviour and the least mean score was negative. According to structural equation modelling, the most important predictor of difficult encounters was an ethical dimension. One-unit increase in ethical behaviour contributed to 0.92 unit increase in positive patient behaviour.

Patients generally are perceived as ‘difficult patient’ by the healthcare professionals, so the patients’ treatment and care services are affected negatively due to healthcare professionals’ negative beliefs and attitudes. The healthcare professionals should behave supportively towards difficult patients.

Healthcare professionals should be aware of management strategies in dealing with difficult encounters. The behaviours of healthcare professionals should be improved in a positive way and awareness of ethical dimension of difficult encounters should be increased.

Nurses who work in an emergency department regularly care for acute patients in a fast-paced environment, being at risk of suffering high levels of burnout. This situation makes them especially vulnerable to be accountable for decisions they did not have time to consider or have been pressured into.

The objective of this study was to find which factors influence ethical, legal and professional accountability in nursing practice in an emergency department.

Data were analysed, codified and triangulated using qualitative ethnographic content analysis.

This research is set in a large emergency department in the Midlands area of England. Data were collected from 186 nurses using participant observation, 34 semi-structured interviews with nurses and ethical analysis of 54 applicable clinical policies.

Ethical approval was granted by two research ethics committees and the National Health Service Health Research Authority.

The main result was the clinical nursing accountability cycle model, which showed accountability as a subjective concept that flows between the nurse and the healthcare institution. Moreover, the relations among the clinical nursing accountability factors are also analysed to understand which factors affect decision-making.

The retrospective understanding of the factors that regulate nursing accountability is essential to promote that both the nurse and the healthcare institution take responsibility not only for the direct consequences of their actions but also for the indirect consequences derived from previous decisions.

The decision-making process and the accountability linked to it are affected by several factors that represent the holistic nature of both entities, which are organised and interconnected in a complex grid. This pragmatic interpretation of nursing accountability allows the nurse to comprehend how their decisions are affected, while the healthcare institution could act proactively to avoid any problems before they happen.

Caring for a partner with primary malignant brain tumour can be a dramatic life-changing event. Primary malignant brain tumour is known to give poor life expectancy and severe neurological and cognitive symptoms, such as changed behaviour and personality, which demand greater caring responsibilities from spouses.

The aim of the study is to explore ethical dilemmas spouses experience in the everyday care of a partner in treatment for primary malignant brain tumour.

A phenomenological and hermeneutic qualitative descriptive design was adopted as a method for collecting and analysing data. Ten spouses were interviewed twice using an in-depth, semi-structured interview guide. The interviews took place at the spouses’ homes or at the hospital.

Ethical matters were considered throughout the research process. Permission from The National Committee on Health Research Ethics and the Danish Data Protection Agency was obtained.

The analysis showed that the spouses perceived daily ethical dilemmas in caring for a partner with primary malignant brain tumour. Their life as well as their partner’s life had changed considerably. The main theme that emerged therefore was ‘oscillating in a changing relationship’. This theme was further elaborated in three subthemes that in more detail demonstrated the dilemmas: ‘doing the right thing in unpredictable daily situations’; ‘torn between patience and guilt’; and ‘living in a time of uncertainty, hope and despair’.

Caring for a partner with changed behaviour and personality due to primary malignant brain tumour may involve exhausting ethical caring dilemmas. Spouses’ married life may change to a semi-professional asymmetrical relationship, which is challenged by the oscillation between acting responsibly for their partners’ well-being and caring dilemmas with no answer for what the right thing to do is. Mixed feelings of right and wrong, patience and guilt, hope and despair seem to be spousal companions through their partners’ progressing illness.

Physical restraint is among the commonly used methods for ensuring patient safety in intensive care units. However, nurses usually experience ethical dilemmas over using physical restraint because they need to weigh patient autonomy against patient safety.

The aim of this study was to explore factors behind ethical dilemmas for critical care nurses over using physical restraint for patients.

This is a qualitative study using conventional content analysis approach, as suggested by Graneheim and Lundman, to analyze the data.

Seventeen critical care nurses were purposefully recruited from the four intensive care units in Tehran, Iran. Data were collected through in-depth semi-structured interviews and were concurrently analyzed through conventional content analysis as suggested by Graneheim and Lundman.

This study was approved by the Ethics Committee of Iran University of Medical Sciences, Tehran, Iran with the code: IR.IUMS.REC.1397.795. Before interviews, participants were provided with explanations about the aim of the study, the confidentiality of the data, their freedom to participate, and the right to withdraw the study, and their free access to the study findings. Finally, their consents were obtained, and interviews were started.

Factors behind ethical dilemmas for critical care nurses over using physical restraint were categorized into three main categories, namely the outcomes of using physical restraint, the outcomes of not using physical restraint, and emotional distress for nurses. The outcomes of using physical restraint were categorized into the three subcategories of ensuring patient safety, physical damage to patients, and mental damage to the patient. The outcomes of not using physical restraint fell into two subcategories, namely the risks associated with not using physical restraint and legal problems for nurses. Finally, the two subcategories of the emotional distress for nurses main category were nurses’ negative feelings about restraint use and uncertainty over the decision on physical restraint use.

Decision-making for restraint use is often associated with ethical dilemmas, because nurses need to weight the outcomes of its use against the outcomes of not using it and also consider patient safety and autonomy. Health authorities are recommended to develop clear evidence-based guidelines for restraint use and develop and implement educational and counseling programs for nurses on the principles of ethical nursing practice, patient rights, physical restraint guidelines and protocols, and management of emotional, ethical, and legal problems associated with physical restraint use.

Nursing errors endanger patient safety, and error reporting helps identify errors and system vulnerabilities. Nursing managers play a key role in preventing nursing errors by using leadership skills. One of the leadership approaches is ethical leadership.

This study determined the level of ethical leadership from the nurses’ perspective and its effect on nursing error and error reporting in teaching hospitals affiliated to Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

This was a cross-sectional descriptive study.

A total of 171 nurses working in medical-surgical wards were selected through random sampling. Data collection was carried out using “ethical leadership in nursing, nursing errors and error reporting” questionnaires. Data were analyzed with SPSS20 using descriptive and analytical statistics.

This study was approved by the Ethics Committee for Medical Research. Ethical considerations such as completing informed consent form, ensuring confidentiality of information, explaining research objectives, and voluntary participation were observed in the present study.

The results showed that the level of nursing managers’ ethical leadership was moderate from the nurses’ point of view. The highest and the lowest levels were related to the power-sharing and task-oriented dimensions, respectively. There was a significant relationship between nursing managers’ level of ethical leadership with error rates and error reporting.

The development of ethical leadership approach in nursing managers reduces error rate and increases error reporting. Programs designed to promote such approach in nursing managers at all levels can help reduce the level of error rate and maintain patient safety.

The occurrence of behavioural changes and problems, and degree of paranoid thoughts, are significantly higher among people who have experienced extreme trauma such as during the Holocaust. People with dementia and traumatic past experiences may have flashbacks reminding them of these experiences, which is of relevance in caring situations. In nursing homes for people with dementia, nursing assistants are often the group of staff who provide help with personal needs. They have firsthand experience of care and managing the devastating outcomes of inadequate understanding of a person’s past experiences.

The aim was to describe nursing assistants’ experiences of caring for older people with dementia who have experienced Holocaust trauma.

A qualitative descriptive and inductive approach was used, including qualitative interviews and content analysis.

Nine nursing assistants from a Jewish nursing home were interviewed.

The study was approved by the Regional Ethical Review Board, Stockholm.

The theme ‘Adapting and following the survivors’ expression of their situation’ was built on two categories: Knowing the life story enables adjustments in the care and Need for flexibility in managing emotional expressions.

The world still witnesses genocidal violence and such traumatic experiences will therefore be reflected in different ways when caring for survivors with dementia in the future. Person-centred care and an awareness of the meaning of being a survivor of severe trauma make it possible to avoid negative triggers, and confirm emotions and comfort people during negative flashbacks in caring situations and environments. Nursing assistants’ patience and empathy were supported by a wider understanding of the behaviour of people with dementia who have survived trauma.