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Purpose To conduct a detailed content analysis of the theme "I'm still Mom" as described by young women living with advanced breast cancer. Participants & setting 12 young adult women living with advanced breast cancer were recruited from across the United States. Methodologic approach van Manen's hermeneutic phenomenologic method was used to analyze qualitative data from interviews and establish subthemes. Findings Women were a mean age of 36 years and had at least one child. The following three subthemes emerged from the overarching theme of I'm still Mom. Implications for nursing This study provides a foundation for additional research that can inform family-centered education and interventions to help align the parenting priorities of this cohort of women, as well as optimize their quality of life.

Background and Purpose 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. Design 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. Methods 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. Findings 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. Conclusions 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. Clinical Relevance 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.

PURPOSE To describe and interpret the lived experiences of young women with advanced breast cancer. PARTICIPANTS A SETTING 12 women, aged 25-39 years with advanced breast cancer, were recruited from private Facebook groups for women with breast cancer. METHODOLOGIC APPROACH Van Manen's hermeneutic phenomenologic method was used. Data were collected through one or more semi-structured interviews over a six-month period. Analysis was conducted using NVivo, version 11. FINDINGS The participants' multidimensional experiences were described by the overarching theme of wearing the mask of wellness in the presence of life-threatening illness. IMPLICATIONS FOR NURSING This study provides insight into the experiences of young women living with advanced breast cancer. Because these women may not appear ill to the general population, their needs and struggles are not well understood. The results of this study can be a baseline for additional research and clinical interventions.

Background: Written reflections on practice are frequently requirements of nursing curricula. They are widely accepted as necessary for improving critical thinking and problem-solving skills. Faculty, are expected to review reflections and provide feedback that helps professional development and facilitates good practice. It is less clear what the actions of nurse educators should be when ethical infractions are revealed in the narratives. Objectives: We had two aims: 1) To combine insights from a literature review of empirical and theoretical research related to responding to ethical issues revealed in student reflections with our experiences reviewing the reflections of undergraduate nursing and midwifery students, and 2) to construct and analyze a hybrid case from these insights in order to develop guidelines for nurse educators. Research Design: A literature review was conducted using CINAHL, MEDLINE, PsycINFO, SocINDEX and ERIC databases and pertinent key words. A hybrid case was constructed of commonly encountered ethical issues using insights from the literature review and the authors’ experiences. The case was analyzed by combining Beauchamp and Childress’ principlist approach with Campbell and McCarthy’s ethical decision-making tool (Table 1). Participants and Research Context: No human participants Findings: A gap in the literature exists related to addressing ethical issues revealed in student practice reflections. However, a combination of insights from the literature and the authors’ experiences facilitated the development of a hybrid case. Subsequent case analysis facilitated the development of a series of guidelines that can be utilized to address a range of issues commonly emerging in the reflections of nursing students during practice experiences. Discussion: A number of recommendations and guidelines are provided to enable the safeguarding of students and staff and support them in practicing ethically. Conclusion: Structured ethical analysis of a constructed hybrid reflection of commonly revealed ethical issues was useful in developing guidelines for educators.

Because health care professions exist to provide a good for society, ethical questions are inherently part of them. Such professions and their members can be assessed based on how effective they are in developing knowledge and enacting practices that further the health and well-being of individuals and society. The complexity of contemporary health care environments makes it important to prepare clinicians who can anticipate, recognize, and address problems that arise in practice or that prevent a profession from fulfilling its service goals and obligations. Different health care professions have evolved distinct perspectives about appropriate goals for, and the purposes of, their clinicians, even when the goal of improving health and well-being for society is shared across professions. While medicine and nursing goals are shared in principle, they differ in the particulars. Given the centrality to nursing of ethical questions, the profession has a collective responsibility to help clinicians at all levels of practice become ethically savvy and to reinforce their moral agency as needed. Both knowledge of nursing ethics and knowledge of the interdisciplinary field of bioethics are critical to nursing work.

Aim To develop and psychometrically assess the Ethical Awareness Scale using Rasch measurement principles and a Rasch item response theory model. Background Critical care nurses must be equipped to provide good (ethical) patient care. This requires ethical awareness, which involves recognizing the ethical implications of all nursing actions. Ethical awareness is imperative in successfully addressing patient needs. Evidence suggests that the ethical import of everyday issues may often go unnoticed by nurses in practice. Assessing nurses' ethical awareness is a necessary first step in preparing nurses to identify and manage ethical issues in the highly dynamic critical care environment. Design A cross-sectional design was used in two phases of instrument development. Method Using Rasch principles, an item bank representing nursing actions was developed (33 items). Content validity testing was performed. Eighteen items were selected for face validity testing. Two rounds of operational testing were performed with critical care nurses in Boston between February-April 2017. Results A Rasch analysis suggests sufficient item invariance across samples and sufficient construct validity. The analysis further demonstrates a progression of items uniformly along a hierarchical continuum; items that match respondent ability levels; response categories that are sufficiently used; and adequate internal consistency. Mean ethical awareness scores were in the low/moderate range. Conclusion The results suggest the Ethical Awareness Scale is a psychometrically sound, reliable and valid measure of ethical awareness in critical care nurses.

Background Surrogate decision makers (SDMs) face difficult decisions at end of life (EOL) for decisionally incapacitated intensive care unit (ICU) patients. Purpose To identify and describe the underlying psychological processes of surrogate decision making for adults at EOL in the ICU. Methods Qualitative case study design using a cognitive task analysis interviewing approach. Participants were recruited from October 2012 to June 2013 from an academic tertiary medical center's ICU located in the rural Northeastern United States. Nineteen SDMs for patients who had died in the ICU completed in-depth semistructured cognitive task analysis interviews. Discussion The conceptual framework formulated from data analysis reveals that three underlying, iterative, psychological dimensions (gist impressions, distressing emotions, and moral intuitions) impact an SDM's judgment about the acceptability of either the patient's medical treatments or his or her condition. Conclusion The framework offers initial insights about the underlying psychological processes of surrogate decision making and may facilitate enhanced decision support for SDMs.

One antidote to moral distress is stronger moral agency-that is, an enhanced ability to act to bring about change. The Clinical Ethics Residency for Nurses, an educational program developed and run in two large northeastern academic medical centers with funding from the Health Resources and Services Administration, intended to strengthen nurses' moral agency. Drawing on Improving Competencies in Clinical Ethics Consultation: An Education Guide, by the American Society for Bioethics and Humanities, and on the goals of the nursing profession, CERN sought to change attitudes, increase knowledge, and develop skills to act on one's knowledge. One of the key insights the faculty members brought to the design of this program is that knowledge of clinical ethics is not enough to develop moral agency. In addition to lecture-style classes, CERN employed a variety of methods based in adult learning theory, such as active application of ethics knowledge to patient scenarios in classroom discussion, simulation, and the clinical practicum. Overwhelmingly, the feedback from the participants (sixty-seven over three years of the program) indicated that CERN achieved transformative learning.

176 Background: Little is known about daily life experiences of young mothers with advanced breast cancer. Limited research suggests they face unique challenges differing from those of women at other life stages and with earlier stages of breast cancer. The larger study aimed to describe and interpret the lived experiences of young women with advanced breast cancer to contribute to our understanding of the needs of this population. Their role as mothers emerged as a significant theme. The goal of the overall study was to inform the development of person-centered interventions. Methods: Van Manen’s hermeneutic phenomenological method was employed in this longitudinal qualitative study. AYA women (25-39 years) with advanced breast cancer were purposively recruited via private Facebook groups specifically for women with breast cancer. Enrollment continued until thematic saturation was achieved. Data were collected through one or more semi-structured interviews over 6 months depending upon participant willingness, desire, or ability. Journals were provided to write additional thoughts. Data were drawn from interviews about daily life experiences. A major theme related to their identities as mothers emerged. Results: Twelve AYA women (mean age: 35.9) were included. All were married, had at least one child (10 months -14 years, median: 6.0 years), and most (n=7, 72.7%) worked full-time. Twelve participated in the first interview, 9 in a second interview, and 6 in a third interview. Three returned journals. The meaning of their experiences as mothers is captured by the theme: “ I’m Still Mom” and 7 subthemes: “ it’s so hard”, ” being a mom still”, “ what I can still do”, “there’s not enough time”, “being remembered”, “searching for resources”, and “ it’s not easy for my kids”. Conclusions: Being a mother is the first priority for these AYA women with advanced breast cancer, but they are hindered in their parenting activities by physical effects of their cancer and its treatment, uncertainty about their future, and worry for their children’s future. This study provides a base for further research on daily priorities for this population to inform future interventions to optimize quality of life consistent with their parenting priorities.

BACKGROUND: The ethics and human rights issues experienced by psychiatric-mental health and substance-abuse registered nurses (P-MH and SA RNs) and how disturbed they are by the issues are not known. OBJECTIVE: The purpose of this study was to identify the frequency of ethics and human rights issues experienced by P-MH and SA RNs and how disturbing the issues are to them. STUDY DESIGN: Using Dillman’s (1978) Total Design Method, a survey of more than 8,000 RNs in six New England states was conducted. From the final sample size of 2,090 New England RN participants, responses from 162 participants who identified themselves as P-MH(n = 145) or SA (n = 17) RNs were further analyzed using descriptive statistics. RESULTS: Protecting patients’ rights and human dignity and providing nursing care with possible health risks to the RN were identified as the most frequently experienced ethics and human rights issues. Staffing patterns that limit patient access to nursing care and implementing managed care policies that threaten the quality of patient care were identified as the most disturbing issues. Forty-one percent of the RNs reported experiencing ethics and human rights issues daily or one to four times per week in their clinical practices. CONCLUSIONS: P-MH and SA RNs in New England encounter ethics and human rights issues in practice more frequently than all other RNs practicing in New England.

The patient says, 'I don't trust hospitals and I don't want strangers in my home!'--how should clinicians respond?

Advocacy is an important concept in nursing practice; it is frequently used to describe th nurse-client relationship. The term advocacy, however, is subject to ambiguity of interpretation. Such ambiguity was evidenced recently in criticisms levelled at the nursing profession by hospital ethicist Ellen Bernal. She reproached nursing for using 'patient rights advocate' as a viable role for nurses. We maintain that, for nursing, patient advocacy may encompass, but is not limited to, patient rights advocacy. Patient advocacy is not merely the defence of infringements of patient rights. Advocacy for nursing stems from a philosophy of nursing in which nursing practice is the support of an individual to promote his or her own well-being, as understood by that individual. It is an ethic of practice. La défense des malades joue un grand rôle dans la pratique des infirmiers/ères. Le terme est souvent utilisé pour définir les rapports entre malades et soignants. Le mot 'defénse' pourtant, peut être mal compris. Une ambiguïté était évidente récemment dans la critique de la profession infirmière faite par la philosophe éthique Ellen Bernal. Elle reproche à la profession d'utiliser le terme 'avocat des droits des malades' pour désigner le rôle primordial des infirmiers/ères. Nous croyons que pour les soignants, la défense des malades peut comprendre le rôle 'd'avocat des droits des malades' mais elle ne s'y borne pas. La défense n'est pas limitée à la défense des infractions des droits des malades. La défense dans la profession infirmière est basée sur une philosophie où la pratique infirmière est le soutien des malades dans leur quête de promouvoir leur propre bien-être. Die Fürsprache spielt eine wichtige Rolle in der Krankenpflege. Sie wird oft als kennzeichnend für die Beziehung zwischen Patient und Pflegepersonal beschrieben. Der Ausdruck 'Fürsprache' kann aber auch mehrdeutig interpretiert werden. Das wurde letzthin in der Kritik der Ethikerin Ellen Bernal an der Krankenpflege sichtbar. Sie machte den Pflegenden den Vorwurf, dass sie sich die Rolle des 'Rechts-Advokat des Patienten' aneignen. Wir sind der Meinung, dass es die Aufgabe des Pflegepersonals ist, auch die Rechte der Patienten zu vertreten, aber dass das nur ein Teil der Fürsprache ist. Sie ist nicht nur Verteidignung von verletzten Patientenrechten. Die Fürsprache in der Krankenpflege stammt von einer Philosophie, deren Ausübung die Unterstützung der Patienten für ihr Wohlergehen zum Ziel hat, so wie die Patienten selbst ihr Wohlergehen verstehen. Sie ist eine Ethik der Tat.

Social justice is asserted as a responsibility of the nursing profession. However, a reliable conception of social justice that can undergird practice, research, education, and policy endeavors has proved elusive. We discuss this as a problem for the profession and propose Powers and Faden's model of social justice as useful for nursing purposes because of its focus on exploring and rectifying underlying causes of injustice as they lie within the fabric of society. Their model asserts 6 essential dimensions of well-being as universal human needs. These dimensions are interrelated and nonhierarchical. A serious deficiency in any one affects other dimensions and interferes with the ability to experience "a minimally decent life." The model is applied to the problem of child abuse and the effects of its aftermath on well-being as an example of its potential for structuring nursing knowledge development, practice, and policy initiatives.

Clinical wisdom, an essential foundation of nursing care that provides for the "good" of individual patients while taking into account the common good, is a concept that is difficult to define and comprehend. However, understanding what constitutes clinical wisdom is essential for the education of the types of nurses who are most likely to provide leadership that is consistent with the goals of nursing as outlined in the 2005 Code of Ethics for Nurses of the International Council of Nurses and the 2001 Code of Ethics for Nurses With Interpretive Statements of the American Nurses Association. The three key elements of wisdom, derived from the psychology and philosophy literature, are (1) balancing and providing for the good of another and the common good, (2) the use of intellect and affect in problem solving, and (3) the demonstration of experience-based tacit knowing in problematic situations. We conceptualized clinical wisdom as a more specific variant of general wisdom by examining how the core elements described can be linked to wisdom for nursing practice. In doing so, the nature of clinical wisdom is clarified and strategies are suggested to assist nurse educators in developing wise nurses.