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Residential psychiatric patients with severe persistent mental illness are often confronted with unbearable existential suffering. This qualitative study aims to describe how psychiatric nurses in Flanders (Belgium) deal with these patients. In view of the data we describe the nursing support for the existential suffering of these patients in terms of a process-related development. In this process of care four phases can be distinguished: meeting and knowing the patient acknowledging the patient as an individual and as a sufferer, building a personal caring relationship based on a bond of trust and on respect for the patient as person, and a concluding phase. The personal caring relationship between nurse and patient is the fundamental element in the care practices. Next we describe the contextual framework inasmuch it can influence the caring process in a restricting or stimulating way. [ABSTRACT FROM AUTHOR]

Objectives The aim of this systematic literature review is to investigate older residents’ thoughts on, experiences of and engagement in sexual behavior and aged sexuality within institutionalized elderly care. Design Systematic literature review. Data sources We conducted an extensive search of the electronic databases Cinahl, Medline, Pubmed, Embase, Web of Science and Invert for papers published between January 1980 and October 2014 when the searches were closed. Additional papers were identified through forward and backward citation chasing. Review methods Data from relevant studies were extracted by means of a data extraction form. Relevant data were isolated, summarized, compared, related and categorized according to theme. Quality assessment of the included studies focused on their adequacy of reporting the study's research aim, sampling, collection, and analysis procedures, ethical considerations and results. Results Twenty-five appropriate studies were identified. These studies varied in research design (using surveys, vignettes, focus groups, interviews, or observation), objectives, quality of reporting, and sample characteristics (i.e. male and/or female long-term care residents with and/or without dementia). Yet, they all point to the relevance of sex and sexuality in old age and emphasize the highly individual character of both sexual interest and expression. Older residents who wish to sexually express themselves, might do this in a wide variety of ways, including, but not limited to, daydreaming, dressing-up, looking for emotional and intellectual intimacy, stroking, caressing, kissing, and engaging in sexual intercourse. Overall, residents appear to have a rather positive attitude toward aged sexuality as such. When it comes to specific sexual behaviors or homosexuality, however, attitudes tend to be more negative. The perceived appropriateness of the displayed behavior is a predominant factor in determining older people's reactions to the sexual behavior of co-residents, rather than the potential emotional discomfort brought on by witnessing this behavior. Conclusions Relatively little work has been published on older residents’ perspectives regarding aged sexuality in institutionalized elderly care. If, however, we wish to devote ourselves to individualized or person-centered nursing care, we will have to gain more insight into the patient's perspective and take notice of the needs, expectations, attitudes, experiences and behaviors of residents with regard to (aged) sexuality. Hence more research is needed that depicts the issue of aged sexuality in institutionalized elderly care from a patient's and thus resident oriented perspective. [ABSTRACT FROM AUTHOR]

In our globalizing world, health care professionals and organizations increasingly experience cross-cultural challenges in care relationships, which give rise to ethical questions regarding “the right thing to do” in such situations. For the time being, the international literature lacks examples of elaborated ethical guidelines for cross-cultural healthcare on the organizational level. As such, the ethical responsibility of healthcare organizations in realizing cross-cultural care remains underexposed. This paper aims to fill this gap by offering a case-study that illustrates the bioethical practice on a large-scale organizational level by presenting the ethical guideline developed in the period 2007–2011 by the Ethics Committee of Zorgnet Vlaanderen , a Christian-inspired umbrella organization for over 500 social profit healthcare organizations in Flanders, Belgium. The guideline offers an ethical framework within which fundamental ethical values are being analyzed within the context of cross-cultural care. The case study concludes with implications for healthcare practice on four different levels: (1) the level of the healthcare organization, (2) staff, (3) care receivers, and (4) the level of care supply. The study combines content-based ethics with process-based benchmarks. [ABSTRACT FROM AUTHOR]

Abstract: Background: Data analysis is a complex and contested part of the qualitative research process, which has received limited theoretical attention. Researchers are often in need of useful instructions or guidelines on how to analyze the mass of qualitative data, but face the lack of clear guidance for using particular analytic methods. Objectives: The aim of this paper is to propose and discuss the Qualitative Analysis Guide of Leuven (QUAGOL), a guide that was developed in order to be able to truly capture the rich insights of qualitative interview data. Method: The article describes six major problems researchers are often struggling with during the process of qualitative data analysis. Consequently, the QUAGOL is proposed as a guide to facilitate the process of analysis. Challenges emerged and lessons learned from own extensive experiences with qualitative data analysis within the Grounded Theory Approach, as well as from those of other researchers (as described in the literature), were discussed and recommendations were presented. Strengths and pitfalls of the proposed method were discussed in detail. Results: The Qualitative Analysis Guide of Leuven (QUAGOL) offers a comprehensive method to guide the process of qualitative data analysis. The process consists of two parts, each consisting of five stages. The method is systematic but not rigid. It is characterized by iterative processes of digging deeper, constantly moving between the various stages of the process. As such, it aims to stimulate the researcher''s intuition and creativity as optimal as possible. Conclusion: The QUAGOL guide is a theory and practice-based guide that supports and facilitates the process of analysis of qualitative interview data. Although the method can facilitate the process of analysis, it cannot guarantee automatic quality. The skills of the researcher and the quality of the research team remain the most crucial components of a successful process of analysis. Additionally, the importance of constantly moving between the various stages throughout the research process cannot be overstated. [Copyright &y& Elsevier]

Abstract: Background: Nurses that care for patients with advanced dementia are increasingly faced with consequences of disease progression, often requiring them to decide whether to artificially feed these patients. Clarifying how nurses can be better supported in complex care processes involving ethically sensitive decision-making requires that their practice be mapped out. Objectives: The aims of this study were to explore and describe how nurses are involved in the care that surrounds decisions concerning artificial nutrition or hydration in hospitalized patients with dementia. Design: We used a qualitative interview design. Data collection and analysis were informed by the grounded theory approach. Setting: Nine hospitals geographically spread throughout the five provinces of Flanders, Belgium. Participants: Twenty-one nurses were purposively selected for interview, with the aim of including nurses that reflected diverse personal characteristics and experiences with the subject matter. Methods: Between April 2008 and June 2009, we conducted 21 interviews that were audiotaped and later transcribed. Data processing involved (1) simultaneous and systematic data collection and analysis, (2) constant forwards-backwards wave, (3) continuous dialogue with the data, and (4) interactive team processes. Results: Nurses’ involvement was characterized by a desire to provide ‘good care’, which was the basis for their motivation and aspiration during the care process. Early in the process, nurses developed a holistic picture of their patients, laying the foundation of their ‘good care’ view. During the actual decision-making, nurses fulfilled the roles of messengers and guiding communicators, as they attempted to realize their ‘good care’ view. Nurses judged the physicians’ decisions in light of their care view. If a decision matched their view, they supported the decision. If not, they resisted it openly or covertly. Some nurses remained passively in the background, while others took action to override the decision. Nurses’ involvement ended with the intensive aftercare of the patients and their family. Conclusions: Nurses are closely and continuously involved in the care that surrounds decisions concerning artificial nutrition or hydration in hospitalized patients with advanced dementia. During the care process, nurses play several and specific roles, giving their contribution a unique and variable character. [Copyright &y& Elsevier]

Background: Today''s healthcare system requires that nurses have strong medical–technical competences and the ability to focus on the ethical dimension of care. For nurses, coping with the ethical dimension of care in practise is very difficult. Often nurses cannot act according to their own personal values and norms. This generates internal moral distress, which has a negative impact on both nurses and patients. Objectives: The objective of this review is a thorough analysis of the literature about nurses’ ethical practise particularly with regard to their processes of ethical reasoning and decision making and implementation of those decisions in practise. Design: We conducted an extensive search of the electronic databases Medline, Embase, Cinahl, and PsycInfo for papers published between January 1988 and September 2008. A broad range of search keywords was used. The 39 selected articles had a quantitative, qualitative, or mixed-method design. Findings: Despite the conceptual difficulties that the literature on the ethical practise of nurses suffers, in this review we understand nurses’ ethical practise a complex process of reasoning, decision making, and implementation of the decision in practise. The process of decision making is more than a pure cognitive process; it is influenced by personal and contextual factors. The difficulties nurses encounter in their ethical conduct are linked to their difficult work environment. As a result, nurses often capitulate to the decisions made by others, which results in a conformist way of acting and less individually adapted care. Conclusions: This review provides us with a more nuanced understanding of the way nurses reason and act in ethically difficult situations than emerged previously. If we want to support nurses in their ethical care and if we want to help them to change their conformist practises, more research is needed. Especially needed are in-depth qualitative studies that explore the experiences of nurses. Such studies could help us better understand not only how nurses reason and behave in practise but also the relationship between these two processes. [Copyright &y& Elsevier]

Abstract: Objective: To describe whether and how Catholic hospitals and nursing homes in Belgium (Flanders) have developed written ethics policies on euthanasia and communicated these policies to their employees, patients, and patient''s relatives. Methods: A cross-sectional mail survey of general directors of Catholic hospitals and nursing homes in Belgium (Flanders). Results: Of the 298 targeted institutions, 81% of hospitals and 62% of nursing homes returned complete questionnaires. A high percentage of Catholic hospitals (79%) and a moderate percentage of nursing homes (30%) had written ethics policies on euthanasia. Both caregivers and healthcare administrators were involved in the development and approval of these policies. Physicians and nurses were best informed about the policies. More than half of the nursing homes (57%) took the initiative to inform both residents and relatives about the policies, while only one hospital did so. Conclusion: The high prevalence of written ethics policies on euthanasia in Flemish Catholic hospitals may reflect the concern of healthcare administrators to maintain the quality of care for patients requesting euthanasia. However, the true contribution of these policies to quality end-of-life care and to supporting caregivers remains unknown and needs further research. Practice implications: Legislation and centrally developed guidelines might influence healthcare institutions to develop ethics policies. [Copyright &y& Elsevier]

Context: Although unanimity exists on using palliative sedation (PS) for controlling refractory physical suffering in end-of-life situations, using it for controlling refractory existential suffering (PS-ES) is controversial. Complicating the debate is that definitions and terminology for existential suffering are unclear, ambiguous, and imprecise, leading to a lack of consensus for clinical practice.Objectives: To systematically identify, describe, analyze, and discuss ethical arguments and concepts underpinning the argument-based bioethics literature on PS-ES.Methods: We conducted a systematic search of the argument-based bioethics literature in PubMed, CINAHL, Embase®, The Philosopher's Index, PsycINFO®, PsycARTICLES®, Scopus, ScienceDirect, Web of Science, Pascal-Francis, and Cairn. We included articles published in peer-reviewed journals till December 31, 2016, written in English or French, which focused on ethical arguments related to PS-ES. We used Peer Review of Electronic Search Strategies protocol, Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and The Qualitative Analysis Guide of Leuven for data extraction and synthesis of themes.Results: We identified 18 articles that met the inclusion criteria. Our analysis revealed mind-body dualism, existential suffering, refractoriness, terminal condition, and imminent death as relevant concepts in the ethical debate on PS-ES. The ethical principles of double effect, proportionality, and the four principles of biomedical ethics were used in argumentations in the PS-ES debate.Conclusion: There is a clear need to better define the terminology used in discussions of PS-ES and to ground ethical arguments in a more effective way. Anthropological presuppositions such as mind-body dualism underpin the debate and need to be more clearly elucidated using an interdisciplinary approach. [ABSTRACT FROM AUTHOR]

Background As care robots become more commonplace in aged-care settings, the ethical debate on their use becomes increasingly important. Our objective was to examine the ethical arguments and underlying concepts used in the ethical debate on care robot use in aged care. Methods We conducted a systematic literature search for argument-based ethics publications focusing on care robot use in aged-care practices. We used an innovative methodology that consisted of three steps: (a) identifying conceptual-ethical questions, (b) conducting a literature search, and (c) identifying, describing and analyzing the ethical arguments in connection with the conceptual-ethical questions. Results Twenty-eight appropriate publications were identified. All were published between 2002 and 2016. Four primary ethical approaches were distinguished: (a) a deontological, (b) a principlist, (c) an objective-list, and (d) a care-ethical. All approaches were equally represented across the articles, and all used similar concepts that grounded their diverse ethical arguments. A small group of publications could not be linked to an ethical approach. Conclusions All included publications presented a strong ethical rationale based on fully elaborated normative arguments. Although the reviewed studies used similar grounding concepts, the studies’ arguments were very diverse and sometimes diametrically opposed. Our analysis shows how one envisions care robot use in aged-care settings is influenced by how one views the traditional boundaries of the ethical landscape in aged care. We suggest that an ethical analysis of care robot use employs “democratic spaces,” in which all stakeholders in aged care, especially care recipients, have a voice in the ethical debate. [ABSTRACT FROM AUTHOR]

Abstract: Background: Institutionalized elderly continue to have the need for sexual expression and intimacy. Nurses often display negative responses when they are confronted with the sexual behavior of residents. They feel ashamed and do not know how to react. This generates feelings of discomfort, resulting in the denial of resident''s needs and desires for sexual fulfillment. Objectives: The objective of this review is to thoroughly analyze the literature about the knowledge, attitudes, and experiences of nursing staff toward sexuality in institutionalized elderly. We shed light onto the relationship between knowledge and attitudes, and determined whether certain demographic factors relate to the knowledge and attitudes of nursing home caregivers. Design: We conducted an extensive search of the electronic databases Medline, Cinahl, Psychinfo, Web of Science, Philosophers Index, Google Scholar, and Invert for papers published between January 1980 and September 2010. A broad range of search keywords was used. Findings: The quantitative studies revealed nursing staff to show rather positive attitudes toward later-life sexuality. However, the extent of the staff''s knowledge regarding sexuality in the aged seemed to be very limited. There was no consensus found about the relationship between knowledge and attitudes. As regards the influence of demographic variables, the results were very ambiguous. The qualitative studies showed that caregivers hold rather conservative attitudes toward sexuality in institutionalized elderly. Feelings of discomfort prevailed. The responses to residents’ sexual behavior were influenced by the staff''s own level of comfort related to sexuality issues and the ethos within the institution where they work. Conclusions: This review gives us a broad outline of the knowledge, attitudes, and experiences of geriatric nurses toward sexuality in institutionalized elderly. If we want the sexual needs of residents to be recognized, more research is needed. Especially needed are more in-depth qualitative studies that explore the experiences of nurses and managers. The development of a more accurate educational program could increase the knowledge of later-life sexuality and cultivate positive and permissive attitudes toward sexuality in the aged. [ABSTRACT FROM AUTHOR]

Abstract: In this paper, we focus on the contexts of moral decision-making by nurses in the euthanasia programs of Nazi Germany between 1939 and 1945 using Urban Walker''s philosophical model. We use the second hypothesis of this model, that morality consists of practices of responsibility, to give an analysis of the understandings nurses had of their responsibilities in the euthanasia programs. The article starts with a brief introduction to the euthanasia programs of Nazi Germany from 1939 to 1945 and nurse participation, to illustrate how the responsibilities of nurses were manipulated. Secondly, nursing as moral practices are analysed in the context of the euthanasia programs that implement commonly shared understandings and practices of responsibility. Thirdly, the reasons that nurses gave for avoiding any responsibilities are examined. Fourthly, it is examined if nurses took any responsibility in the euthanasia programs. In conclusion, this paper discusses three points of relevance such a reflection on moral responsibility in the context of Nazi Germany has for nurses today who may be confronted with euthanasia. [Copyright &y& Elsevier]

Objectives There is growing evidence of the potential effectiveness of advance care planning. Yet important knowledge gaps remain regarding the preconditions for successful implementation of advance care planning in the nursing home setting. We aim to identify the preconditions related to successful advance care planning in the nursing home setting. By specifying those, we would be able to make well-founded choices for the future design and planning of advance care planning intervention programs. Design A systematic review. Data sources PubMed, PsycINFO, EMBASE and CINAHL. Review methods Two authors independently screened publications. One author assessed methodological quality and extracted textual data, which was double-checked for a random sample. We extracted textual data and used thematic synthesis to identify “preconditions”, defined as requirements, conditions and elements necessary to achieve the desired outcome of advance care planning, i.e. attaining concordance between residents' preferences and actual care or treatment received at the end of life. Main findings Based on 38 publications, we identified 17 preconditions at five different levels: resident, family, health-care professional, facility and community. Most preconditions were situated on multiple levels but the majority addressed professionals and the nursing home itself. We summarized preconditions in five domains: to have sufficient knowledge and skills, to be willing and able to participate in advance care planning, to have good relationships, to have an administrative system in place, and contextual factors supporting advance care planning within the nursing home. Conclusion There are multiple preconditions related to successfully implementing advance care planning in the complex nursing home setting that operate at micro, meso and macro level. Future interventions need to address these multiple domains and levels in a whole-system approach in order to be better implementable and more sustainable, while simultaneously target the important role of the health-care professional and the facility itself. [ABSTRACT FROM AUTHOR]

Abstract: Context: Culture has a profound influence on our understanding of what is appropriate care for patients at the end of life (EoL), but the evidence base is largely nonexistent. Objectives: An international workshop was organized to compile a research agenda for cultural issues in EoL research, and assess challenges and implications of the integration of the culture concept in different contexts. Methods: Participant experts were identified from the expert network established through an Internet-based call for expertise on culture and EoL care and from meetings. The workshop comprised presentations of research priorities from country and disciplinary perspectives, and group discussions. Analysis used all data gathered in the workshop and applied standard qualitative techniques. Results: Thirty experts participated in the workshop and identified the following priorities for cross-cultural research: 1) clarifying the concepts of culture and cultural competence; 2) defining EoL in a context of social and cultural diversity, with a focus on concepts of EoL care and bioethics, experiences of receiving and giving EoL care, and care practices in different settings; and 3) developing appropriate methodologies and outcome measurements that address diversity. Conclusion: This first pan-European meeting compiled a research agenda, identifying key areas for future research focusing on culture, diversity, and their operationalization. This requires international and multidisciplinary collaboration, which is necessary in the current efforts to synthesize best practices in EoL care. [Copyright &y& Elsevier]

Abstract: Objective: To describe the form and content of ethics policies on euthanasia in Flemish hospitals and the possible influence of religious affiliation on policy content. Methods: Content analysis of policy documents. Results: Forty-two documents were analyzed. All policies contained procedures; 57% included the position paper on which the hospital''s stance on euthanasia was based. All policies described their hospital''s stance on euthanasia in competent terminally ill patients (n =42); 10 and 4 policies, respectively, did not describe their stance in incompetent terminally and non-terminally ill patients. Catholic hospitals restrictively applied the euthanasia law with palliative procedures and interdisciplinary deliberations. The policies described several phases of the euthanasia care process – confrontation with euthanasia request (93%), decision-making process (95%), care process in cases of no-euthanasia decision (38%), preparation and performance of euthanasia (79%), and aftercare (81%) – as well as involvement of caregivers, patients, and relatives; ethical issues; support for caregivers; reporting; and practical examples of professional attitudes and communication skills. Conclusion: Euthanasia policies go beyond summarizing the euthanasia law by addressing the importance of the euthanasia care process, in which palliative care and interdisciplinary cooperation are important factors. Practice implications: Euthanasia policies provide tangible guidance for physicians and nurses on handling euthanasia requests. [Copyright &y& Elsevier]

Abstract: In many European countries there is a public debate about the acceptability and regulation of euthanasia. In 2002, Belgium became the second country after the Netherlands to enact a law on euthanasia. Although euthanasia rarely occurs, the complexity of the clinical–ethical decision making surrounding euthanasia requests and the need for adequate support reported by caregivers, means that healthcare institutions increasingly need to consider how to responsibly handle euthanasia requests. The development of written ethics policies on euthanasia may be important to guarantee and maintain the quality of care for patients requesting euthanasia. The aim of this study was to determine the prevalence, development, position, and communication of written ethics policies on euthanasia in Flemish nursing homes. Data were obtained through a cross-sectional mail survey of general directors of all Catholic nursing homes in Flanders, Belgium. Of the 737 nursing homes invited to participate, 612 (83%) completed the questionnaire. Of these, only 15% had a written ethics policy on euthanasia. Presence of an ethics committee and membership of an umbrella organization were independent predictors of whether a nursing home had such a written ethics policy. The Act on Euthanasia and euthanasia guidelines advanced by professional organizations were the most frequent reasons (76% and 56%, respectively) and reference sources (92% and 64%, respectively) for developing ethics policies on euthanasia. Development of ethics policies occurred within a multidisciplinary context. In general, Flemish nursing homes applied the Act on Euthanasia restrictively by introducing palliative procedures in addition to legal due care criteria. The policy was communicated to the consulting general practitioner and nurses in 74% and 89% of nursing homes, respectively. Although the overall prevalence of ethics policies on euthanasia was low in Flemish nursing homes, institution administrators displayed growing awareness of bearing responsibility for stimulating dialogue and reflection about how to deal with euthanasia requests within their institution. [Copyright &y& Elsevier]

Abstract: Background: Although nurses worldwide are confronted with euthanasia requests, how nurses experience their involvement in euthanasia remains unclear. Objectives: To explore nurses’ involvement in the care for patients requesting euthanasia. Design: A qualitative grounded theory strategy. Setting: Two general hospitals (A, B) and a palliative care setting in Flanders (Belgium). Participants: Nurses who fulfilled the following inclusion criteria: (a) Dutch-speaking; (b) working for at least one year in hospital A or B; (c) working at least part-time (⩾50%); and (d) ever received a euthanasia request. We collected data using purposeful sampling, superseded by theoretical sampling in a palliative care setting. The sample included one intensive care nurse, one oncology nurse, eight palliative care nurses, and five internal medicine nurses. All but five were women. Their age ranged from 24 to 49 years. Methods: We conducted one-on-one semi-structured interviews between November 2001 and September 2002. Grounded theory was applied for guiding data collection and analysis. The trustworthiness of data was ensured by several strategies. Results: Although euthanasia was still illegal, the nurses unanimously stated that they had an important role in caring for patients requesting euthanasia. Their personal and intense involvement caused them to experience a spectrum of emotions, chief among them being a sense of powerlessness. Several elements contributed to the nurses’ conflicted involvement. Nurses became frustrated if the context (e.g., lack of time) hindered their efforts to provide compassionate care. The palliative care setting and its associated culture (group mentality, care philosophy) created the opportunity for nurses to take time to holistically support patients and their relatives. Conclusions: Hospital nurses are confronted with patients’ euthanasia requests. Each stage of this process requires that the nurses possess specific competencies. Their willingness to personally care for these patients, in addition to their specific care expertise, allows them to be skilled companions. [Copyright &y& Elsevier]