Vol 12 (2019)
The relationship between moral distress in nurses and ethical climate in selected hospitals of the Iranian social security organization
The present study was conducted to determine the relation between nurses’ moral distress and the ethical climate in selected hospitals of the Iranian Social Security Organization (ISSO). This descriptive-analytical correlational study was conducted in 6 hospitals under the coverage of the Iranian Social Security Organization in 2016. Three hundred nurses were selected by convenience sampling method. Data were gathered using Corley’s Standard Moral Distress and Olson’s Hospital Ethical Climate Scales. Data were analyzed using SPSS software version 19.
The mean score of the nurses’ moral distress was 1.94 ± 0.66, which is considered moderate. The mean score of ethical climate was 88.97, indicating desirable ethical climate in these hospitals. The frequency score of moral distress had a unilateral reverse correlation with the total score of ethical climate as well as its dimensions, including colleagues, patients, hospitals and physicians. The score of the intensity of nurses’ moral distress also had a unilateral reverse correlation with the total score of ethical climate and the scores of the hospital and physicians dimensions.
These results emphasized the importance of creating a positive ethical climate to decrease moral distress as well as the need for professional interventions to increase support in moral issues.
Factors influencing the attitudes of NICU physicians toward care of neonates with very poor prognosis
Attitudes of physicians toward neonates with poor prognosis greatly influence their decisions regarding the course of treatment and care. The present study aimed to investigate factors contributing to attitudes of medical practitioners toward poor prognosis neonates. This was a cross-sectional, descriptive-analytic study. Questionnaires for assessing subjects’ attitudes toward care of very poor prognosis neonates were administered to all neonatologists, pediatricians, neonatology assistants, and pediatric residents (a total of 88 individuals) working in the NICUs of Imam Khomeini Hospital. Participants’ attitudes were determined through analysis of responses to seven questions on a 5-point Likert scale ranging from “strongly agree” to “strongly disagree”.
Presence of anomalies incompatible with an acceptable quality of life, birth weight, gestational age, responses to neonatal diagnostic tests, certain types of diseases, parental marital status and practitioner predictions about patient prognosis were the factors contributing to practitioners’ attitude (P-value < 0.005). However, no significant relationship was found in connection with religious beliefs, socioeconomic status, opinions of consulting physicians, hospital treatment protocols, standards of the Association of Neonatal Physicians, and ethics committee expectations (P-value > 0.005). It can be concluded that the attitudes of practitioners toward intensive care of poor prognosis neonates is determined by the medical condition of the neonate rather than socio-demographic characteristics.
Lived experiences of nursing students about ethical concerns of using mobile learning in educational and clinical contexts
The field of education has experienced a profound change following the introduction of mobile technology over the last decades, and nursing education is not an exception. This study explored the experiences of nursing students about the ethical concerns regarding the use of mobile devices for learning purposes, that is, mobile learning, in educational and clinical contexts. A qualitative phenomenological study was carried out on nursing students (n = 19) in Saveh University of Medical Sciences of Iran between December 2017 and April 2018. Data
were collected through semi-structured interviews with openended questions. Data analysis was done using Colaizzi’s 7-step method, revealing four the mes and nine sub-themes including: 1) preserving professional dignity (in front of the patient, and the teacher, and preserving academic virtual identity); 2) securing
informed consent and respecting personal (the patient’s and teachers) autonomy; 3) proper and efficient use (observing the regulations and codes, and making educational use); and 4) avoiding harm (responsible use of class and patient data). It was revealed that using mobile technology in education could raise ethical concerns for nursing students, and this should be emphasized in nursing educational programs.
Ethical considerations in the biomedical research: analysis of national biomedical research ethics guidelines in Iran
The national guidelines for biomedical research ethics are approved by the “National Committee for Ethics in Biomedical Research” at the Iranian Ministry of Health and Medical Education as the regulatory body for biomedical research in the country. The focus of these guidelines should be on the ethical issues related to different stages of the research process, which would lead to increased research integrity and better supervision of research activities. The present study analyzed the contents of these national guidelines to clarify the ethical considerations connected to the five stages of a research process including 1) proposing, 2) approval, 3) operation, 4) documentation and 5) publishing. The findings showed that the assessed guidelines laid more emphasis on the ethical considerations related to the research operation stage rather than the proposal stage. In other words, activities such as identification of the research problem, formulation of hypotheses and questions, financial evaluation, data analysis and data interpretation did not receive adequate attention in these guidelines. Most of the guidelines presented subject categories such as the rights of participants and supervisory considerations in the “research operation stage”, ethical considerations in the “evaluation and approval procedure stage”, and editorial responsibilities in the “research review and publication stage”. In general, despite noticeable content for guiding researchers for ethical conduction of research the national guidelines are not adequately developed to cover comprehensive and sufficient ethical considerations regarding all the activities of research.
A study of the validity and reliability of the questionnaire entitled “physicians' approach to and disclosure of medical errors and the related ethical issues”
Medical errors are among the major challenges that threaten patients’ health worldwide. The aim of this study was to design a valid and reliable questionnaire to investigate the status of medical error disclosure by physicians.
A preliminary questionnaire was developed based on the extracted results from 37 interviews with specialists. To test the validity of the questionnaire, 20 medical practitioners and medical ethics authorities were asked to evaluate the relevance and clarity of each item. To measure the instrument’s reliability (the intra-class correlation coefficient and Cronbach’s alpha), a test-retest study was conducted on 20 randomly selected physicians twice with a 2-week interval. Statistical analyses were performed using SPSS software version 20.
The overall relevance and clarity of the instrument, with an average approach, were measured at 97.22 and 94.03 percent respectively. The Cronbach’s alpha, which presents the internal consistency was satisfactory (0.70 - 0.79) for various domains of the questionnaire. The range of intra-class correlation coefficients for the items in all domains of the questionnaire was 0.76 to 1.00.
Regarding the validity and reliability of the questionnaire, it can be an appropriate instrument in the assessment and monitoring of the status of medical error disclosure by physicians.
Blood is a public resource of human origin and its transfusion process is essential to individual and public health. This study aimed to develop a national code of ethics for blood donation and transfusion (BDT).
This was a qualitative research with a multi methods approach in which a combination of methods including situational analysis, focus group discussion and expert panels were used. After situational analysis and orientation, the code of ethics for BDT was developed based on the findings of a content analysis within the framework of the four principles of biomedical ethics.
The results were categorized into two sections: situational analysis and underpinnings measures, and the clauses of the code. The Iranian Blood Transfusion Organization has carried out three essential supportive measures over the past decades: approval of insurance coverage of blood recipients against communicable diseases; inclusion of 14 blood services in the book of “Relative Value Units of Health Services”; and formation of the National Ethics Committee of Transfusion Medicine. After recognition and orientation, the national code of ethics for BDT was adopted and imparted to blood donation centers. The code consists of two sections: “Blood Transfusion Centers: Donors and Donation” in 19 clauses, and “Hospitals: Patients” in 8 clauses.
The national code of ethics for BDT establishes moral norms in order to protect the rights of blood donors and recipients. It could also serve as a basis for addressing the related ethical challenges and right decision-making in the area of BDT.
Professional socialization is defined as a process through which a person becomes a legitimate member of a professional society. This will have a great impact on an individual’s professional conduct and morality. The aim of this study was to clarify this concept and reduce the ambiguities around it.
This was a qualitative research through which the concept of professional socialization was analyzed using Walker and Avant’s eight-step approach. The review of literature for this concept was done using electronic database without any time limitation. The overall search produced about 780 articles, and after reviewing these articles, 21 were selected purposefully.
Based on concept analysis, we propose the following analytical definition: Professional socialization is a nonlinear, continuous, interactive, transformative, personal, psychosocial and self-reinforcing process that is formed through internalization of the specific culture of a professional community, and can be affected by individual, organizational and interactional factors. This definition is in accordance with the interactionism perspective. Existence of a particular profession and getting involved in a community of practice are the antecedents of this process, and formation of professional identity and professional development are its consequences. A case model, as well as borderline and related cases, has been introduced for this concept. The results of this study can be used to design useful educational interventions to conduct and facilitate the process.
Validity, reliability and acceptability of Professionalism Mini-Evaluation Exercise (P-MEX) for emergency medicine residency training
Professionalism is a core competency in the medical profession. In this paper, we aimed to confirm the validity, reliability and acceptability of the Professionalism Mini-Evaluation Exercise (P-MEX) instrument for the emergency medicine (EM) residency program. Twenty-two EM attending physicians completed 383 P-MEX forms (the Persian version) for 90 EM residents. Construct validity was assessed via structural equation modeling (SEM). The reliability coefficient was estimated by the generalizability theory, and acceptability was assessed using two researcher-made questionnaires to evaluate the perspectives of residents and assessors. There was a consensus among the participants regarding the content of P-MEX. According to the results of SEM, the first implementation of the original model was associated with a moderate fit and high item loadings. The model modified with correlated error variances for two pairs of items showed an appropriate fit. The reliability of P-MEX was 0.81 for 14 occasions. The perception survey indicated high acceptability for P-MEX from the viewpoint of the residents and increasing satisfaction with P-MEX among the assessors over time.
According to the results of the research, P-MEX is a reliable, valid, and acceptable instrument for assessing professionalism in EM residents.
Clinical teachers as positive and negative role models: an explanatory sequential mixed method design
Today, role modeling is an essential component of medical education that facilitates the students' learning and affects their attitudes and behaviors. Hence, this study aimed to examine the characteristics of positive and negative role models using a mixed method approach. In the quantitative part, data were collected using a questionnaire with 24 items. The research population included medical students who were in their clinical period between May 2017 and December 2018 at Shiraz University of Medical Sciences (n = 750). A total of 282 questionnaires were completed by these students, and in the qualitative part, 26 semi-structured interviews were conducted with them.
The most important components of role modeling for students included: individual characteristics, clinical skills and competence, teaching skills and professionalism, in that order. The qualitative analysis confirmed the results of the quantitative analysis. The findings showed that the characteristics of a negative role model can also be classified in four main components. The results demonstrated that 46.8% of the students identified one or more medical teachers as negative models.
Students paid attention to not only the positive characteristics of their teachers, but also their negative features, stating that they had been influenced by both. Therefore, it can be concluded that clinical teachers should improve their performance as positive role models through reducing these negative effects and reinforcing positive characteristics.
Perspectives of Hinduism and Zoroastrianism on abortion: a comparative study between two pro-life ancient sisters
Hinduism and Zoroastrianism have strong historical bonds and share similar value-systems. As an instance, both of these religions are pro-life. Abortion has been explicitly mentioned in Zoroastrian Holy Scriptures including Avesta, Shayast-Nashayast and Arda Viraf Nameh. According to Zoroastrian moral teachings, abortion is evil for two reasons: killing an innocent and intrinsically good person, and the contamination caused by the dead body (Nashu). In Hinduism, the key concepts involving moral deliberations on abortion are Ahimsa, Karma and reincarnation. Accordingly, abortion deliberately disrupts the process of reincarnation, and killing an innocent human being is not only in contrast with the concept of Ahimsa, but also places a serious karmic burden on its agent. The most noteworthy similarity between Zoroastrianism and Hinduism is their pro-life approach. The concept of Asha in Zoroastrianism is like the concept of Dharma in Hinduism, referring to a superior law of the universe and the bright path of life for the believers. In terms of differences, Zoroastrianism is a religion boasting a God, a prophet, and a Holy book, while Hinduism lacks all these features. Instead of reincarnation and rebirth, Zoroastrianism, like Abrahamic religions, believes in the afterlife. Also, in contrast with the concept of Karma, in Zoroastrianism, Ahura Mazda can either punish or forgive sins.
Elder abuse is an increasingly intangible phenomenon that has created numerous ethical issues for care teams and caregivers. Although different studies have concentrated on various ethical issues regarding abuse, no study has arrived at a comprehensive conclusion. Therefore, the present study aimed to determine the existing ethical challenges in this context.
For this purpose, two researchers familiar with systematic search approach examined national and international journals on PubMed, Excerpta Medica Database (EMBASE), Scientific Information Database (SID) and similar databases between January and February 2017. They were able to find 116 articles that met the inclusion and exclusion criteria, and finally selected 15 articles based on the predesigned questions.
The findings were classified in five subtitles as follow: 1) the common definition of elder abuse, 2) a comprehensive legislation on elder abuse, 3) comprehensive ethical principles about elder abuse, 4) ethical considerations regarding patients without competency, and 5) reporting and sharing information about elder abuse. The study results revealed no common definition and no legislation about elder abuse, and also showed that health care providers’ observance of ethical principles depends on the ethical and legal conditions of the community.
Nowadays, elder abuse is a serious problem in many countries. Cultural and religious differences are the reasons for lack of a common definition and legislations, which comprises the biggest obstacle to protecting the rights of elderly people. It is clear that ethical principles should be respected as far as a person has competency. Furthermore, localization of clinical guidelines related to this issue leads to proper functioning of health care providers, especially nurses as the first line of treatment.
The so-called Trolley Problem was first discussed by Philippa Foot in 1967 as a way to test moral intuitions regarding the doctrine of double effect, Kantian principles and utilitarianism. Ever since, a great number of philosophers and psychologists have come up with alternative scenarios to further test intuitions and the relevance of conventional moral doctrines. Given that physicians routinely face moral decisions regarding life and death, the Trolley Problem should be considered of great importance in medical ethics. In this article, five “classic” trolley scenarios are discussed: the driver diverting the trolley, a bystander pulling a lever to divert the trolley, a fat man being thrown from a bridge to stop the trolley, a bystander pulling a lever to divert a trolley so that a fat man may be run over, and a bystander pulling a lever so that a fat man falls off from a bridge to stop the trolley. As these scenarios are discussed, relevant moral differences amongst them are addressed, and some of the applications in medical ethics are discussed. The article concludes that Trolley scenarios are not the ultimate criterion to make ethical decisions in difficult ethical challenges in medicine cases but they do serve as an initial intuitive guide.
Using animals for cosmetics and medical tests has contributed towards a debate based on conflicting interests. Despite the efforts in justifying the value of animals in conducting analyses, this study seeks to elaborate whether or not it is rational to use animals as test subjects in medical and cosmetics fields. The value of animal life is at the core of the emotional conflicts that arise when animals become experimental subjects in medical and cosmetics fields. The aim of this study is to determine if there are ethical differences in the use of animal testing in medicine versus cosmetics. The research, through review and content analysis of the existing literature, compares and provides the outcomes of using animals in medical and cosmetics tests by examining studies conducted in the UK. The findings of this research indicated that animal testing is considered acceptable in the medical field only if there are no other alternatives, but is completely unacceptable in the cosmetics field. The study also provides recommendations in the form of alternatives that protect animals from cruelty and may benefit the different stakeholders and the society at large.
In continuation with the New Thought movement that arose in the United States in the 19th Century, there is now a massive self-help industry that markets books and seminars. This industry has also extended to healthcare in the form of positive thinking, i.e., the idea that happy thoughts are essential for health. While some of these claims may seem reasonable and commonsensical, they are not free of problems. This article posits that positive thinking has some ethical underpinnings. Extreme positive thinking may promote alternative forms of medicine that ultimately substitute effective treatment, and this is unethical. The emphasis on positive thinking for cancer patients may be too burdensome for them. Likewise, unrestricted positive thinking is not necessarily good for mental health. After considering the ethics of positive thinking, this article proposes a more realistic approach.
The aim of this paper is to compare “Zapiski Vracha” (“Confessions of a Physician”, first published in 1901) by Vikenty Veresaev to “Aerztliche Ethik” (“Doctors’ Ethics”, first published in 1902; two Russian editions were published in 1903 and 1904) by Albert Moll. It starts with an overview of medical ethics in Russia at the turn of the 20th century in relation to zemstvo medicine, followed by reception of Veresaev’s “Confessions of a Physician” by Russian and German physicians, and of Moll’s “Doctors’ Ethics” in Russia. Comparison of these two books may serve as a good example of a search for common philosophical foundations of medical ethics as well as the impact of national cultural traditions.
Cannabis abuse has been an issue of major concern for the Albanian society in recent years, following the wide illegal planting of the species. Legal lacunas, weaknesses from the drug-controlling agencies, and the easiness of harvesting Cannabis sativa plants have contributed to the creation of a general negative opinion toward a potential use of its active principles for medical purposes. Professionals of the field and policymakers are largely focused on harm reduction activities, thus bypassing the option of legalizing cannabinoids for clinical conditions that might find relief in their use.The discussion of a case suffering from postherpetic neuralgia shows how this negative opinion is depriving Albanian patients from an otherwise helpful pharmacological option whose efficacy has been confirmed by an important bulk of research. Uncovering the roots of this misperception will help address the issue. Clinicians with expertise need to have their say in the debate, since for the majority of countries where medicinal cannabis is legalized, this was due to consumer-led initiatives. Ensuring patients’ freedom as implied within the principle of autonomy is also a sound ethical support of such legalization.
Really Good Stuff
Many studies have attempted to analyze the concept of professionalism in nursing. Prior to this study, however, there had been no experience of empowering nurses to train their peers. The context of nursing is different from other professions in the health system. In comparison to physicians, nurses’ exposure to patients is not only more frequent, but also of a kind that urges them to behave in a professional manner that differs from physicians and medical students.
The use of narratives as narrative discourse is a tool used to express the experiences of individuals (1). In medical sciences, the use of the narrative approach has been emphasized by Rita Charon (2). Researchers who have used a narrative approach in medical education claim that practicing narrative writing can improve health care provision (3 - 6). In the health care system, narration is the usage of literature on patients' stories to facilitate clinical decision-making for physicians. Lately, the narrative has applied a healing potential as “narrative care”, a method that uses story to improve health care. This approach focuses on patients' stories (7). The narrative plays a very effective role in making difficult ethical decisions, and therefore it is important to keep considerations and consequences in mind (8).
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