Jurchak Martha, Grace Pamela J, Lee Susan M, Willis Danny G, Zollfrank Angelika A, Robinson Ellen M
Executive Director, Ethics Service, Brigham and Women's Hospital, Boston, MA, USA.
Alpha Chi, Associate Professor, Boston College, William F. Connell School of Nursing, Chestnut Hill, MA, USA.
J Nurs Scholarsh. 2017 Jul;49(4):445-455. doi: 10.1111/jnu.12297. Epub 2017 Jun 12.
Nurses face complex ethical issues in practice and have to determine appropriate actions. An inability to conceptualize or follow a preferred course of action can give rise to moral uncertainty or moral distress. Both moral uncertainty and moral distress are problematic for nurses and their patients. A program designed to increase nurse confidence in moral decision making, the clinical ethics residency for nurses (CERN), was offered selectively to nurses affiliated with two academic medical centers. This is a report of the analysis of their application essays.
Over a 3-year period, 67 application essays were analyzed using conventional content analysis. Applicants comprised one third advanced practice nurses (APNs) and two thirds staff nurses. They were asked to describe their reasons for interest in the CERN and how they would apply the knowledge gained.
For conventional content analyses, no theoretical presumptions are used; rather, codes are identified from the data in an iterative manner and eventually collapsed into themes. Initially, broad themes were identified by the CERN team. Subsequently, in-depth and recursive readings were completed by a subset of three members, resulting in refinement of themes and subthemes.
The overarching theme identified was "developing abilities to navigate through the 'grey zones' in complex environments." Three subthemes were: (a) nurses encountering patients who are chronically critically ill, culturally diverse, and presenting with complex circumstances; (b) nurses desiring enhanced ethics knowledge and skills to improve quality of care, understand different perspectives, and act as a resource for others; and (c) nurses supporting and facilitating patient-centered ethical decision making.
Findings are consistent with those appearing in the international literature but provide a more cohesive and comprehensive account than previously, and hold promise for the development of educational and policy strategies to address moral distress and uncertainty.
This study is relevant to clinical practice in its verification of the need nurses have for ethics knowledge, skill refinement, and application through communication. These findings affirmed the challenge that nurses feel in communicating their ethical concerns in an effective and engaging way and their commitment to advocacy and improvement in the quality of care for patients.
护士在实践中面临复杂的伦理问题，必须确定适当的行动方案。无法构思或遵循首选行动方案可能会导致道德不确定性或道德困扰。道德不确定性和道德困扰对护士及其患者来说都是问题。一项旨在增强护士道德决策信心的项目，即护士临床伦理住院医师培训（CERN），已选择性地提供给与两家学术医疗中心相关联的护士。这是对他们申请文书分析的报告。
在3年期间，使用传统内容分析法对67篇申请文书进行了分析。申请者中三分之一是高级实践护士（APN），三分之二是普通护士。他们被要求描述对CERN感兴趣的原因以及他们将如何应用所学知识。
对于传统内容分析，不使用理论假设；相反，从数据中以迭代方式识别代码，最终归纳为主题。最初，CERN团队确定了宽泛的主题。随后，由三名成员组成的一个子集完成了深入和递归阅读，从而完善了主题和子主题。
确定的总体主题是“培养在复杂环境中穿越‘灰色地带’的能力”。三个子主题是：（a）护士遇到患有慢性危重病、文化背景多样且情况复杂的患者；（b）护士希望增强伦理知识和技能，以提高护理质量、理解不同观点并成为他人的资源；（c）护士支持并促进以患者为中心的伦理决策。
研究结果与国际文献中的结果一致，但比以前提供了更具凝聚力和全面性的描述，并为制定解决道德困扰和不确定性的教育及政策策略带来了希望。
本研究与临床实践相关，它验证了护士对伦理知识、技能提升以及通过沟通进行应用的需求。这些发现证实了护士在以有效且引人入胜的方式传达其伦理关切时所感受到的挑战，以及他们对倡导和改善患者护理质量的承诺。
