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Nurses are trusted to be truthful and to provide considered, substantiated information in a neutral way. Yet the COVID-19 crisis has highlighted how some nurses engage in misinformation on social media and in other venues. This article explores the reasons why people believe they are fully informed, including the possible influence of confirmation biases. It also describes the augmented ethical responsibilities of nurses to examine in depth what they think they know and understand and to account for cognitive biases. Strategies for nurse leaders, managers, and educators are provided to facilitate good practice and help ensure nurses are held accountable for their actions and social media postings.

To enhance patient care in the inevitable conditions of complexity that exist in contemporary healthcare, collaboration among healthcare professions is critical. While each profession necessarily has its own primary focus and perspective on the nature of human healthcare needs, these alone are insufficient for meeting the complex needs of patients (and potential patients). Persons are inevitably contextual entities, inseparable from their environments, and are subject to institutional and social barriers that can detract from good care or from accessing healthcare. These are some of the reasons behind current movements to develop competency frameworks that can enhance cross-disciplinary communication and collaboration. No single profession can claim the big picture. Effective teamwork is essential and requires members of diverse professions to understand the nature of each other's knowledge, skills, roles, perspectives, and perceived responsibilities so that they are optimally utilized on behalf of patients and their families. Interdisciplinary approaches to care permit different aspects of a person's needs to be addressed seamlessly and facilitate the removal of obstacles by engaging the range of resources exemplified by the different professions. Additionally, collaborative efforts are needed to influence policy changes on behalf of individual and social good and to address root causes of poor health especially as these impact society's most vulnerable. Here, we explore both the benefits and the risks of an uncritical acceptance of competency frameworks as a way to enhance interdisciplinary communication. We highlight the importance of anchoring proposed competency domains in the reason for being of a given profession and exemplify one way this has been accomplished for advanced practice nursing. Additionally, we argue that having this mooring, permits integration of the various competencies that both enhances professional moral agency and facilitates interdisciplinary collaboration to further the mutual goals of the healthcare professions on behalf of quality patient care.

Evidence suggests that healthcare professionals feel inadequately equipped to manage ethical issues that arise, resulting in ethics-related stress. Clinical ethics consultation, and preventive ethics strategies, have been described as ways to decrease ethics-related stress, however information is limited regarding specific sources of ethical concern.The purpose of this study was to conduct a retrospective, longitudinal analysis of a comprehensive database of ethics consultations, at a major academic medical center in the Northeast United States in order to: (1) Discern major sources of ethical concern, (2) Evaluate how these have changed over time in their content and frequency, (2a) Evaluate trends in nurse versus physician-initiated requests.Six major reasons for requesting an ethics consult were identified: Conflict Over Goals of Care, Decisional Capacity, Withholding/Withdrawing Treatment, Proxy Decision Making, Communication, and Behavior. Themes were operationally defined by the study team. An increase in requests related to Conflict Over Goals of Care (β = 0.7, 95% CI = 0.2-1.2,This study revealed several noteworthy and previously unidentified trends in consultation requests, and several important distinctions between the sources of ethical concern nurses identify versus those physicians identify. These findings can be used to develop future preventive-ethics frameworks.

Nurses are trusted to be truthful and to provide considered, substantiated information in a neutral way. Yet the COVID-19 crisis has highlighted how some nurses engage in misinformation on social media and in other venues. This article explores the reasons why people believe they are fully informed, including the possible influence of confirmation biases. It also describes the augmented ethical responsibilities of nurses to examine in depth what they think they know and understand and to account for cognitive biases. Strategies for nurse leaders, managers, and educators are provided to facilitate good practice and help ensure nurses are held accountable for their actions and social media postings.

Background: Ethical awareness (EA) enables nurses to recognize the ethical implications of all practice actions and is an important component of safe and quality nursing care. Evidence suggests tha...

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 More older couples are living independently while managing chronic health conditions. Though research is replete in identifying the influence of spouse's behaviours on each other's health, there is little known of the specific factors underlying the older couples' relational processes to explain this dynamic. Knowledge development is needed to provide a grounding for interventions to address such influences to improve health and well-being. AIM The aim of this study was to advance the understanding of older couples' experiences of living with chronic health conditions to gain insights into the potential benefits of 'being a couple' to manage behavioural health and life adjustments. METHOD A hermeneutic-dialectic phenomenology design based on Newman's theory of Health as Expanding Consciousness was used. Fourteen older couples were jointly interviewed. The interviews were non-structured and designed to capture their experience as a couple. RESULTS Three themes emerged (a) living meaningfully through mutual caregiving, (b) a pattern of spousal movement facilitating change and (c) co-creating as an older couple to move forward. CONCLUSION The study supports reframing older couple's care as a 'dyad of care'. This approach provides an opportunity to leverage the couples' mutuality to support health management as a couple. A motivation to action process between the spouses appeared to enable mutual caregiving, a reliance of each spouse on the another for identity, socialisation, health and daily living, which facilitated an evolving understanding of their lives and its meaning. IMPLICATIONS FOR PRACTICE Mutual caregiving should be acknowledged as a significant relational dynamic within older couples, as a dyad of care, when managing health and well-being.

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.

Background: The Clinical Ethics Residency for Nurses was offered selectively to nurses affiliated with two academic medical centers to increase confidence in ethical decision-making. Research Question/Aim: To discover how effective the participants perceived the program and if their goals of participation had been met. Research design: A total of 65 end-of-course essays (from three cohorts) were analyzed using modified directed content analysis. In-depth and recursive readings of the essays by faculty were guided by six questions that had been posed to graduates. Ethical considerations: Institutional review board approval was granted for the duration of the program and its reporting period. Confidentiality was maintained via the use of codes for all evaluations including the essays and potentially identifying content redacted. Findings: An umbrella theme emerged: participants had developed ethical knowledge and skills that provided a “moral compass to navigate the many gray areas of decision-making that confront them in daily practice.” Six major themes corresponding to questions posed to the participants included the ability to advocate for good patient care; to support and empower colleagues, patients, and families; they experienced personal and professional transformation; they valued the multimodal nature of the program; and were using their new knowledge and skills in practice. However, they also recognized that their development as moral agents was an ongoing process. Discussion: Findings support that enhancing nurse confidence in their moral agency with a multimodal educational approach that includes mentored practice in ethical decision-making, enhancing communication skills and role-play can mitigate moral distress. A majority found the program personally and professionally transformative. However, they recognized that ongoing ethics discussion involvement and supportive environments would be important in their continued development of ethical agency. Conclusion: Multimodal ethics education programs have potential to be transformative and enhance nurse confidence in their ethical decision-making.

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.

The nursing profession has a responsibility to ensure that nursing goals and perspectives as these have developed over time remain the focus of its work. Explored in this paper is the potential problem for the nursing profession of recognizing both the promises and pitfalls of informational technologies so as to use them wisely in behalf of ethical patient care. We make a normative claim that maintaining a critical stance toward the use of informational technologies in practice and in influencing the thought patterns of the younger generations of nurses is a moral imperative of the discipline, because without this practice can become subverted from professional goals in various ways. We use a synthesized concept we call "intentional authenticity" derived from the writing of Heidegger and Feminist care ethics to provide a foundation for the development of nurses who understand the importance of the nurse-patient relationship and how the unthoughtful use of informational and other technologies can militate against effective or good nursing care.

Doctorally prepared nurses must be able to represent the unique nursing perspective within interdisciplinary teams to address contemporary health challenges. This article provides a student exemplar applying the unifying focus of facilitating humanization as described by Willis, Grace, and Roy to science on nature and health. As scientific knowledge becomes more complex, nurses must be skilled in translating information through the nursing lens to support individuals in realizing meaning, choice, quality of life, and healing in living and dying. In order for doctoral students to shepherd the discipline, they must first integrate nursing's philosophical underpinnings into their practice.

Confusion remains about the concept "nursing science." Definitions vary, depending on country, context and setting. Even among nurse scholars and scientists there is disagreement about the content and boundaries of nursing science. There is an urgent need for an acceptable definition that can guide nursing knowledge development, education, and practice. In this article, we highlight the problems for the profession of this sort of conceptual ambiguity, arguing that it is an ethical responsibility for the profession to gain clarity about the meaning and apt focus of our knowledge development initiatives. We parse out nursing and science as separate concepts and synthesize from this analysis a simple yet comprehensive definition of nursing science. We propose that this definition is capable of unifying ongoing nursing endeavors and should serve as the basis for evaluating nursing's knowledge development and educational initiatives.

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.

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.

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.

Philosophical inquiry remains critically important for nursing education, practice, and knowledge development. We propose a 3-level taxonomy of philosophical inquiry to guide nursing curricula and research development. Important background information about philosophy and the development of philosophical methods is given. Then philosophical inquiry is linked to the goals of nursing using our proposed taxonomy: level I-cultivating an attitude of "critical consciousness" related to all nursing situations and actions, level II-analysis and application of philosophical perspectives to nursing problems and level III-generating new knowledge for nursing purposes including new theories of practice and research.

This article expands upon previous work by the authors to develop a model of nursing essential and effective freedom to facilitate nursing action in behalf of social justice. The article proposes that while social justice is rooted in nursing's ontological, epistemological, and moral foundations, the discipline's social justice mandate is constrained by its historical and contemporary location within an institutionalized medical paradigm. We present a model of nursing "essential" and "effective" freedom based on the philosophy of Bernard Lonergan to illustrate how nursing can transcend these barriers. This humanizing model is illustrated through personal narratives of the authors.

Gaining in-depth understanding of the experiences of persons who have suffered traumatic events with physical and psychological sequelae is important for building effective interventions. However, qualitative research of this kind can be emotionally difficult for the researcher whose research interests derive from practice experiences with the population studied. It may be difficult for the researcher to separate the role of inquirer from that of practitioner. We explore this issue using ethical analysis to differentiate the responsibilities of the researcher from those of the clinician. In the first part of the chapter, we provide some background on the population studied and traumatic spinal cord injury and its aftermath as context for the issues raised by the narrative. Then, we describe briefly the first author's research exploring the meaning of bodily changes and embodiment in persons who have suffered a traumatic spinal cord injury. We provide the part of Jack's story that most troubled the researcher and led her to discuss the situation with an ethics colleague. Finally, we use the tools of moral reasoning, ethical analysis, and principles of research ethics to explore the pertinent excerpt of the narrative. The resulting clarifications are laid out for the reader with the intent of assisting other qualitative researchers in determining the extent and limits of their obligations to participants of qualitative studies, especially those that explore sensitive issues.

Nursing has a rich history of knowledge development, yet there remains ambiguity about what is a proper central unifying focus for the discipline. At this time in our history, it is imperative that we clearly define and articulate who we are and what we offer. Confusion about a central unifying focus is a significant problem for practice given the current healthcare environment and global problems affecting health and healing. The authors propose a central unifying focus for the discipline: facilitating humanization, meaning, choice, quality of life, and healing in living and dying. This focus will serve as a basis for our professional identity, strengthen our endeavors, and provide the ontological and epistemological basis for our continuing evolution as a practice profession.

The purpose of a practice discipline's terminal degree is to develop wise scholars to guide the profession in anticipating and meeting the health-related needs of those served via philosophical, conceptual/theoretical, and empirical inquiry on behalf of professional practice. Each of these dimensions is important for the discipline's ability to meet its obligations to society. However, contemporary circumstances have created a context within which the maturation of the profession may be threatened by an imbalance among the three dimensions of PhD education. Specifically, we discuss the possibility of a tilt toward the empirical at the expense of the other two. Yet, the philosophical and conceptual/theoretical dimensions are those that have permitted core disciplinary knowledge to be developed. We aim to create a dialog about current challenges and the responsibilities of the discipline's scholars for stewardship of the discipline and offer some strategies to ensure balance among the three equally important dimensions.

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 profession of nursing has a critical potential and mandate to advance social justice in order to further health for vulnerable communities. Social injustice, or the societal conditions that lead to dehumanization for certain populations, has a significant impact on human health. But realizing this potential requires the nursing profession to liberate itself from prevailing conventional views that nursing is practiced mainly within the confines of medical institutions and is consequently largely subject to the rules and structural constraints imposed by others. Nursings mandate to advance social justice emerges from the ontological, epistemological, and ethical foundations of the profession as well as its own historical development. Several social factors have been linked with adverse human health outcomes including the corporate concentration of wealth and power, environmental hazards, collective violence and discrimination. The global impact of social factors on health inequality has been further articulated by the World Health Organizations (WHO) Commission on Social Determinants of Health.

Advocacy has proven a slippery concept for nursing. Although the nursing profession has adopted the term ‘patient advocacy’ to denote an ideal of practice, the meaning, scope and implications of the concept have not yet been adequately defined. Poorly defined concepts lead to practice problems and these ultimately impact patient care. This article clarifies some basic underlying assumptions of the term ‘advocacy’ in the interest of facilitating the goals of nursing. The origins and meanings of the term are traced. It is noted that ‘advocacy’ as descriptive of verbal actions on behalf of others is an expression initially used in legal settings. Nursing's use of this term is explored and because the term is also discovered in the literature of other disciplines to denote either a standard (Law) or ideal (Medicine) of practice it proved helpful to compare the various perspectives. Additionally, the link between advocacy and notions of professional responsibility, obligation and accountability is investigated. Although advocacy for nurses is discovered to be a broad concept it has typically been seen as applying to individual situations and immediate contexts. However, actions taken with the purpose of advocating for a given patient (or group of patients) necessarily affect more than the person for the sake of whom the actions are taken. Thus, patient advocacy commits nurses to an examination both of the immediate practice environment and of the wider context in which nursing occurs. This is because nursing's purpose of furthering ‘health’ extends both to individuals and society. For these reasons it is suggested that the term ‘professional advocacy’ viewed as actions stemming from professional role objectives more accurately captures the scope of nursing responsibilities than does either ‘advocacy’ or ‘patient rights advocacy’.

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.

This article uses an exemplar of phenomenological research of middle school boys, experiences of being bullied as applied philosophy and science to illuminate the intersection of the moral and scientific realms for theory-oriented research and practice. As a consequence, a clear foundation for advancing nursing science and envisioning innovative nursing practice with boys who experience being bullied is provided. Included is a weaving together of phenomenological perspective for research and practice, Roger's (nursing) Science of Unitary Human Beings (SUHB), and SUHB-derived middle range theories of self-transcendence and power.

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.