Nursing Ethics

The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress.

Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon.

Systematic literature review and narrative synthesis (November 2015–March 2016).

Ovid MEDLINE^® In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO^® 1967–Present, CINAHL^® Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education Abstracts.

Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis.

In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity.

We suggest the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.

Moral distress is a very common experience in the nursing profession, and it is one of the main reasons for job dissatisfaction, burnout, and quitting among nurses. For instance, morally difficult situations in taking care of child patients who are severely ill may lead to moral distress for nurses. However, most of the studies about moral distress have been conducted on nurses of special wards and adult medical centers with much focus on developed countries. Subsequently, little has been researched on this topic among nurses in other nations such as Iran, and most certainly, there has been hardly any such research involving Iranian pediatric nurses.

This study was conducted to evaluate moral distress among nurses in selected pediatric hospitals in Tehran, Iran.

This cross-sectional study was conducted on eligible nurses who were selected through proportional stratified sampling and who completed demographic characteristics and the pediatric version of Moral Distress Scale-Revised questionnaires. Data were analyzed using descriptive statistics, t test, one-way analysis of variance, and Pearson correlation coefficient.

In total, 195 pediatric nurses working at three selected children’s specialized university hospitals in Tehran participated in this study.

This study was evaluated and approved by the institutional review board of Tehran University of Medical Sciences.

The mean and standard deviation of total score of moral distress was 106.41 ± 61.64 within a range of 10–257. Also, the difference between the mean score of moral distress of the group who had not quitted their position and those who have quit in the past was statistically significant (p = 0.043). The situation that was associated with the highest moral distress was “observing medical students performing painful procedures on patients just to gain some skill.” Total score of moral distress was significantly higher among male nurses (p = 0.014), while nurses with a master’s degree experienced just a higher intensity of moral distress compared to those who had a bachelor’s degree (p = 0.006).

Since many pediatric nurses clearly face moral distress while taking care of children, it is necessary to consider measures for preventing or decreasing situations that would lead to this distress.

A growing number of frameworks for the practice of clinical ethics are described in the literature. Among these, hermeneutical frameworks have helped highlight the interpretive and contextual nature of clinical ethics practice.

The aim of this article is to further advance this body of work by drawing on the ideas of Charles Taylor, a leading hermeneutical philosopher.

A Hermeneutical Rapprochement Framework is presented for clinical ethics practice, based on Taylor’s hermeneutical “retrieval” and “rapprochement.” This builds on existing hermeneutical approaches for the practice of clinical ethics by articulating a framework with interpretive and reconciliatory scope that extends beyond the presenting “local” context. A Hermeneutical Rapprochement Framework considers broader socio-historical horizons and imaginaries grounded on Taylor’s expansive work in epistemological, ontological, political, and moral philosophy.

The framework is discussed in terms of how it can be operationalized for clinical practice as well as normative development. Implications for the educational preparation of clinical ethicists are also discussed. Although this work is directly relevant for clinical ethicists, it can also help inform the ethical practice of all clinicians.

The research on nursing professionals in Clinical Ethics Committees and Nursing Ethics Commissions occurs in different parts of the world; however, little information on this subject is found in the literature.

This study analyzed national and international publications in relation to the participation of nursing professionals in Clinical Ethics Committees.

This was an integrative review of articles published in national and international journals between 1994 and 2016 which described the participation of nursing professionals in ethics commissions.

A total of 35 articles were selected.

The thematic categories were the need for time to discuss ethical issues; ethics committee to reduce the moral suffering of professionals; competencies required for participation; and barriers/difficulties and facilitators for implementation/ performance. It was concluded that professionals recognize the need for ethics committees to foster discussions. However, barriers hamper operation and fundamental competencies for participation. Communication of committee activities to professionals and educational activities may be major allies to improve the functioning of these committees.

Nurses’ voices remain unheard in most debates about euthanasia, although their crucial role in the euthanasia process is widely acknowledged. Moreover, in Canadian euthanasia law, nurses have a more active role, which further highlights the need for knowledge about nurses’ attitudes towards their role in the euthanasia process.

What are Finnish nurses’ attitudes towards their potential role in the euthanasia process? Which characteristics are associated with those attitudes?

Cross-sectional web-based survey.

1003 nurses, recruited via social media and the members’ bulletin of the Finnish Nurses Association.

Ethical approval was obtained from the Committee on Research Ethics of the university to which the first author was affiliated.

The great majority (85.2%) of nurses felt that their perspective should be considered in decision-making related to euthanasia. Furthermore, most of the participants (74.7%) reported willingness to participate in the euthanasia process if it were legal, and 88.6% agreed that a nurse should be present when euthanasia is performed if the patient wishes so. Furthermore, over half agreed that some of the preparatory tasks were part of their job description. However, a minority (32.9%) agreed with a possible obligation to participate based on their profession. Nurses’ age, religiosity and educational level influenced their attitudes in the current results.

Despite the strong agreement on decision-making concerning euthanasia and participation in the euthanasia process, obligation to participate based on the profession was rejected by most participants. Nurses regarded themselves as consultants in the decision-making process, which may indicate their unwillingness to share the responsibility for the decision itself.

Specific safety mechanisms should be considered to protect nurses who refuse to be involved in the euthanasia process due to harm that involuntary participation might cause.

Research suggests that nurses generally do not participate in ethical decision-making in accordance with ethical guidelines for nurses. In addition to completing their training, nurses need to reflect on and use ethically grounded arguments and defined ethical values such as patient’s dignity in their clinical work.

The purpose of this article is to gain a deeper understanding of how nurses deal with ethical decision-making in daily practice. The chosen research question is “How do nurses participate in ethical decision-making for the patient?”

We use Gadamer’s philosophical hermeneutics as well as Kvale and Brinkmann’s three levels of understanding in interpreting the data material. Nine registered nurses were interviewed.

The Ombudsman of Norwegian Social Science Data and the head of the hospital approved the investigation. The participants received both oral and written information about the study and they gave their consent. We informed the participants that the participation was voluntary and that they were free to withdraw at any point in the course of the study. The requirement of anonymity and proper data storage was in accordance with the World Medical Association Declaration of Helsinki (1964). The participants were assured that privacy, and confidentiality would be duly protected.

Four key themes emerged: (1) confusion in relation to professional and operational expectations of role, (2) ideal somnolence, (3) inadequate argumentation skills, and (4) compound pressure.

Ethical ideals appear to be latent in the mindset of the participants; however, the main finding of this investigation is that nurses need to activate the ideals and apply them into practice. Furthermore, management needs to initiate professional reasoning and interdisciplinary discussions leading to common goals for patients.

Adolescents can be vulnerable to diminished dignity in the hospital because young people have significantly different healthcare needs than children and adults. They like to cooperate with caregivers only when they get respectful and dignified care. Care without considering dignity can adversely influence the adolescents’ recovery. However, many studies have been conducted on exploring the concept of the patients’ dignity from the adult patients and fewer studies still have explored the dignity of young people.

This study explores the hospitalized adolescents’ perception about dignity.

A conventional qualitative content analysis method was used to explore the meaning of hospitalized adolescents’ dignity.

Hospitalized adolescents in general medical and surgical pediatric units were eligible to participate. Data were obtained through unstructured interviews. Purposive sampling was used and adolescents were recruited until data saturation was reached (n = 13).

Ethical approval for the study was granted by the Ethics Committee of Shiraz University of Medical Sciences. Participants were provided with information about the purpose, reasons for recording interviews, voluntary participation, and confidentiality of data and interviewees.

Dignity was reflected in four themes: (1) protection of personal privacy, (2) protection of autonomy, (3) respect for identity, and (4) intimate communication.

Hospitalized adolescents stated that healthcare services should protect their personal privacy and autonomy. Also, they should respect the adolescent’s identity and communicate intimately with them to provide the dignity. Adolescence is a discrete developmental stage, with specific healthcare needs which must be addressed effectively by healthcare providers especially nurses.

Maintaining patient’s dignity in intensive care units is difficult because of the unique conditions of both critically-ill patients and intensive care units.

The aim of this study was to uncover the cultural factors that impeded maintaining patients’ dignity in the cardiac surgery intensive care unit.

The study was conducted using a critical ethnographic method proposed by Carspecken.

Participants included all physicians, nurses and staffs working in the study setting (two cardiac surgery intensive care units). Data collection methods included participant observations, formal and informal interviews, and documents assessment. In total, 200 hours of observation and 30 interviews were performed. Data were analyzed to uncover tacit cultural knowledge and to help healthcare providers to reconstruct the culture of their workplace.

Ethical approval for the study from Ethics committee of Isfahan University of Medical Sciences was obtained.

The findings of the study fell into the following main themes: “Presence: the guarantee for giving enough attention to patients’ self-esteem”, “Instrumental and objectified attitudes”, “Adherence to the human equality principle: value-action gap”, “Paternalistic conduct”, “Improper language”, and “Non-interactive communication”. The final assertion was “Reductionism as a major barrier to the maintaining of patient’s dignity”.

The prevailing atmosphere in subculture of the CSICU was reductionism and paternalism. This key finding is part of the biomedical discourse. As a matter of fact, it is in contrast with dignified care because the latter necessitate holistic attitudes and approaches.

Changing an ICU culture is not easy; but through increasing awareness and critical self-reflections, the nurses, physicians and other healthcare providers, may be able to reaffirm dignified care and cure in their therapeutic relationships.

Despite the growing importance of spiritual care, the delivery of spiritual care is still an area of disagreement among healthcare providers.

To develop a grounded theory about spiritual care delivery based on Iranian nurses’ perceptions and experiences.

A qualitative study using the grounded theory approach.

Data were collected through holding 27 interviews with 25 participants (17 staff nurses, 3 physicians, 3 patients, 1 family member, and 1 nurse assistant). The study setting was the Imam Khomeini Hospital Complex. Sampling was started purposively and continued theoretically. Data analysis was performed by the method proposed by Strauss and Corbin.

The study was approved by the Ethics Committee of Tarbiat Modares University and the agreement of the administrators of the study setting was got before starting the study.

The core category of the study was “Trust building” which reflected the nature of spiritual care delivery by nurses. Trust building was the result of eight main categories or strategies including creating a positive mentality at hospital admission, understanding patients in care circumstances, having a caring presence, adhering to care ethics, developing meaningful relationships, promoting positive thinking and energy, establishing effective communication with patients, and attempting to create a safe therapeutic environment. Poor interprofessional coordination negatively affected this process while living toward developing greater cognizance of divinity and adhering to the principles of professional ethics facilitated it. The outcome of the process was to gain a sense of partial psychological security.

The “Trust building” theory can be used as a guide for describing and expanding nurses’ roles in spiritual care delivery, developing care documentation systems and clinical guidelines, and planning educational programs for nursing students and staff nurses.

A total of 71,000 people in Norway suffer from some form of dementia in 2013, of whom approximately 30,000 are in nursing homes. Several studies focus on the experiences of those who have close relatives and who are staying in a nursing home. Results show that a greater focus on cooperation between nursing staff and relatives is a central prerequisite for an increased level of care. Benefits of developing systematic collaboration practices include relief for nursing staff, less stress, and greater mutual understanding. Going through studies focusing on the experiences of nursing home patients’ relatives, negative experiences are in the majority. In this study, relatives are invited to share positive experiences regarding the care of their loved ones; a slightly different perspective, in other words.

The aim of the study is to investigate relatives of persons with dementia’s experiences with quality care in nursing homes.

The study is a part of a larger project called Hospice values in the care for persons with dementia and is based on a qualitative design where data are generated through narrative interviews. The chosen method of analysis is the phenomenological–hermeneutical method for the study of lived experiences.

Participants in the project were eight relatives of persons with dementia who were living in nursing homes, long-term residences. The sampling was targeted, enrolment happened through collective invitation. All relatives interested were included.

The Norwegian Regional Ethics Committee and the Norwegian Social Science Data Services approve the study.

Findings show that relatives have certain expectations as to how their loved ones ought to be met and looked after at the nursing home. The results show that in those cases where the expectations were met, the relatives’ experiences were associated with engagement, inclusion and a good atmosphere. When the expectations were not met, the relatives experienced powerlessness, distrust and guilt.

The results are discussed considering the concepts of trust, power and asymmetry.

When asked about experiences with quality care, the relatives spoke both of expectations met and of expectations not met. Results in this study are important knowledge for developing units where performing quality care is the overall aim.

The concept of professional commitment is being widely studied at present. However, although it is considered an indicator for the most human part of nursing care, there is no clear definition for it, and different descriptors are being used indiscriminately to reference it.

The aim of this study is to clarify the concept of professional commitment in nursing through the Rodgers’ evolutionary concept analysis process.

Systematic search using English and Spanish descriptors and concept analysis. Studies published between 2009 and June 2015, front-to-back analysis of the Nursing Ethics journal and manual check of articles cited in studies related to the Nijmegen Professionalism Scale.

The procedure of concept analysis developed by Rodgers was used.

Although the topic was not labeled as sensitive and subject to ethical approval, its realization was approved by the Ethical Committee of Clinical Research of Aragon (CEICA) approved the study on 18 March 2015 and also careful procedures have been followed according to ethics expressed in the Declaration of Helsinki.

A total of 17 published studies. A clear definition of the concept was made, and surrogate terms, concept dimension, differential factors related to the concept, sociocultural variations and consequences for nursing practice were identified.

There is a need for continuous advancement in the development of the concept, specific actions to encourage this and the improvement of evaluation methods for its study.

In China, research ethics is a subject of increasingly formal regulation. However, little is known about how nursing researchers understand the concept of research ethics and the ways in which they can maintain ethical standards in their work.

The aim of this study is to examine nursing researchers’ perspectives on research ethics in China.

We conducted a descriptive qualitative study. Qualitative research methods enabled us to gain an in-depth understanding of nursing researchers’ views on research ethics.

We carefully selected and extensively interviewed 28 nursing researchers, nursing faculty, and clinical nurses who had been involved in research or who may undertake research in the future. We collected data between October 2014 and March 2015.

This study was approved by the institutional review boards of Yale University and Central South University.

We grouped the data into five categories based on the interviewees’ responses: (1) perceptions of ethics, bioethics, and research ethics; (2) perception of the ethics review process; (3) perception of the function of institutional review boards; (4) the need for comprehensive ethical guidelines for future studies; and (5) ethical challenges faced by the interviewees.

This study contributes new insights into nursing researchers’ views on research ethics in China and finds considerable shortcomings in researchers’ understanding and implementation of ethical principles. Intensive educational efforts are needed to provide nursing researchers, institutional review board members, and even study subjects with accurate and up-to-date information and guidance on research ethics. In addition, while Western research ethics theoretically have guided Chinese clinical research for several years, the ways in which nursing researchers have implemented these ethical standards highlight the differences between the Eastern and Western ethical paradigms. This finding suggests the need for ethical standards that are more tailored to the Chinese context.

Rising levels of burnout and decreasing job satisfaction can inhibit healthcare professionals from providing high-quality care due to a corresponding decrease in their ethical sensitivity.

This study aimed to determine the relationship between the level of ethical sensitivity in emergency service nurses and their levels of burnout and job satisfaction.

This research employed a descriptive and cross-sectional design.

This study was conducted with a sample of 236 nurses, all of whom worked in emergency service between 24 July 2015 and 28 April 2016. Data were collected using the Moral Sensitivity Questionnaire, Maslach Burnout Inventory, and Minnesota Job Satisfaction Scale.

This study was approved by the Institutional Ethics Review Board of Ondokuz Mayıs University.

There was a weak and negative correlation (r = –0.158, p = 0.015) between Moral Sensitivity Questionnaire and Maslach Burnout Inventory scores. There was also a weak and negative correlation (r = –0.335, p < 0.001) between the Maslach Burnout Inventory and Minnesota Job Satisfaction Scale scores.

Decreased job satisfaction and increased burnout levels among emergency service nurses might result in them indulging in improper practices, frequently facing ethical problems, and a decrease in the overall quality of service in hospitals. In order for emergency service nurses to recognize ethical problems and make the most accurate decisions, a high level of ethical sensitivity is critical. In this respect, it is suggested that continuing education after graduation and training programs should be organized.

Moral sensitivity has been identified as a foundational component of ethical action. Diminished or absent moral sensitivity can result in deficient care. In this context, assessing moral sensitivity is imperative for designing interventions to facilitate ethical practice and ensure that nurses make appropriate decisions.

The main purpose of this study was to validate a scale for examining the moral sensitivity of Brazilian nurses.

A pre-existing scale, the Moral Sensitivity Questionnaire, which was developed by Lützén, was used after the deletion of three items. The reliability and validity of the scale were examined using Cronbach’s alpha and factor analysis, respectively.

Overall, 316 nurses from Rio Grande do Sul, Brazil, participated in the study.

This study was approved by the Ethics Committee of Research of the Nursing School of the University of São Paulo.

The Moral Sensitivity Questionnaire contained 27 items that were distributed across four dimensions: interpersonal orientation, professional knowledge, moral conflict and moral meaning. The questionnaire accounted for 55.8% of the total variance, with Cronbach’s alpha of 0.82. The mean score for moral sensitivity was 4.45 (out of 7).

The results of this study were compared with studies from other countries to examine the structure and implications of the moral sensitivity of nurses in Brazil. The Moral Sensitivity Questionnaire is an appropriate tool for examining the moral sensitivity of Brazilian nurses.

Academic ethical awareness is an important aspect especially for nursing students who will provide ethical nursing care to patients in future or try to tread the path of learning toward professional acknowledgement in nursing scholarship.

The purpose of this study was to explore academic ethical awareness and its related characteristics among undergraduate nursing students.

This study commenced the survey with cross-sectional, descriptive questions and enrolled convenient samples of 581 undergraduate nursing students from three universities in South Korea. It was investigated with structured questionnaires including general characteristics and academic ethical awareness related.

This study was reviewed and approved by the Institutional Review Board at National University.

Academic ethical awareness was the highest regarding behaviors violating the respect or confidentiality of patients and cheating on exams, while it was the lowest for inappropriate behaviors in class. From the result of general characteristics difference, male students showed higher score than female students in relative; first-year students showed higher score than other year students; the higher score was rated from students who were highly satisfied with their major than the other not satisfied with their major; and students with low academic stress showed higher ethical awareness score than persons with higher stress.

Personal behaviors were rated with low ethical awareness in relative, but items related to public rules and actual effects on patients or others were rated with higher score. Nursing satisfaction and academic stress are main factors on ethical awareness. To improve overall ethical awareness level of nursing students, it is required to provide more education about the importance of personal behaviors in class and need to improve the understanding of how it will be connected with future situation and effect.

Ascertaining the relationship between ethical ideology, moral judgment, and ethical decision among academic nurse educators at work appears to be a challenge particularly in situations when they are faced with a need to solve an ethical problem and make a moral decision.

This study aims to investigate the relationship between ethical ideology, moral judgment, and ethical decision as perceived by academic nurse educators.

A descriptive correlational research design was conducted at Faculty of Nursing, Alexandria University. All academic nurse educators were included in the study (N = 220). Ethical Position Questionnaire and Questionnaire of Moral Judgment and Ethical Decisions were proved reliable to measure study variables.

Approval was obtained from Ethics Committee at Faculty of Nursing, Alexandria University. Privacy and confidentiality of data were maintained and assured by obtaining subjects’ informed consent.

This study reveals a significant positive moderate correlation between idealism construct of ethical ideology and moral judgment in terms of recognition of the behavior as an ethical issue and the magnitude of emotional consequences of the ethical situation (p < 0.001; p = 0.031) respectively. Also, there is a positive significant moderate correlation between relativism construct of ethical ideology and overall moral judgment (p = 0.010). Approximately 3.5% of the explained variance of overall moral judgment is predicted by idealism together with relativism.

The findings suggest that variations in ethical position and ideology are associated with moral judgment and ethical decision.

Organizations of academic nursing education should provide a supportive work environment to help their academic staff to develop their self-awareness and knowledge of their ethical position and promoting their ethical ideologies and, in turn, enhance their moral judgment as well as develop ethical reasoning and decision-making capability of nursing students. More emphasis in nursing curricula is needed on ethical concepts for developing nursing competencies.

Nurses engaging in research are held to research ethics standards.

Examine experiences, behaviors, and perceptions of nurses in Israel regarding research ethics and explore possible related factors.

An original investigator-designed self-administered questionnaire measured five variables: (a) ethics in research, (b) encountered research misconduct during the course of one’s studies, (c) the inclination to fabricate data, (d) the inclination to select or omit data, and (e) knowledge of research misconduct in the workplace. Additionally, demographic data were collected.

The questionnaire was completed by 151 Israeli registered nurses. 10.2% hold a PhD, 34 % hold an MA, 42.2% hold a BA, and 13.6% with no academic degree.

The study was approved by the University’s ethics committee; anonymity and consent of the respondents were respected.

Registered nurses’ level of studies achieved was significantly associated with a lower inclination to fabricate data, with one exception—PhD nurses were more inclined to fabricate data than nurses with a Master’s degree. A trend was found in which a higher level of studies is associated with higher knowledge of research misconduct in the workplace.

Results indicate that nurses’ perceptions of research ethics change throughout their academic studies, indicating a positive influence of level of studies, research experience, and work experience on ethics perceptions. Nevertheless, PhD nurses showed a greater inclination to actually select, omit, or even fabricate data than MA nurses. This may be related to pressure to publish.

PhD nursing programs should include ethics training. Academic faculty members should serve as role models regarding research integrity. Research ethics deserves further emphasis on all levels of nurse education in Israel, as well as in the nurses’ code of ethics and related documents. This may positively impact ethical research practices.

In order to prove their commitment to the nursing profession, nurses need to base their professional activities on certain acknowledged values. Although a large number of studies have addressed professional values in nursing, only a few studies are available on the identification and comparison of nurses’, nursing students’, and nursing instructors’ understanding of such values.

The study aims to compare nurses’, nursing students’, and nursing instructors’ perception of nursing professional values.

In this descriptive-comparative study, data were collected using Weis and Schank’s Nurses’ Professional Values Scale–Revised. The data were analyzed using the SPSS statistical software (v 22).

A total of 299 nurses, 341 nursing students, and 100 nursing instructors from multisite, 20 different wards from 3 university hospitals and associated nursing schools located in the cities of Shiraz, Fasa, and Jahrom in Fars province, participated in 2016.

The Institutional Review Board of the researchers’ primary university has verified that the study complies with research ethics.

The total mean scores of the nurses’, nursing students’, and nursing instructors’ perception were found to be 4.23 (0.44), 3.92 (0.50), and 4.34 (0.35), respectively, in the domain of justice—this domain was the subjects’ top priority—and 3.40 (0.56), 3.29 (0.49), and 3.55 (0.36), respectively, in the domain of activism—this domain was attached the least importance by the subjects. There were significant differences across the three groups’ perception in all of the dimensions of professional values (p < 0.001).

The three study groups’ overall mean scores fall within the range of relatively important or important. Several studies show the same results, but there are still controversies in this regard.

There is need for plans to increase nurses’ awareness of certain professional duties and improve their professional performance in all areas alongside their care duties.

New graduate transition into the workforce is challenging and can involve managing ethical tensions. Ethical tensions cause new graduates to doubt their capabilities due to their lack of experience. To support new graduates, we need to know what these ethical tensions are.

To explore the ethical tensions perceived to occur in practice for new graduate health professionals.

This qualitative systematic review involved a search of five databases (Medline, EMBASE, AMED, CINAHL and Scopus) which resulted in the retrieval of 3554 papers. After the two-phased screening process, eight studies were identified that met the inclusion criteria and had rich data on the review question. Articles were read several times, critically appraised and analysed through thematic analysis.

No ethical approval was required for the systematic review. The review was conducted following well-established reporting guidelines enabling transparency and rigour.

Studies originated from Australia, United States, Iran and China. One study included speech pathologists and seven were with nurses. Four themes included the following: (1) enduring an unknown workplace culture that generates uncertainty without support for new graduates; (2) being vulnerable because of distress from bullying, exclusion and being a scapegoat; (3) constraining systems and institutional restrictions that cause dilemmas; and (4) experiencing disillusionment from lost ideals about ethical practice.

This review has brought to light the vulnerability of new graduates to negative workplace culture and collegial incivility. In addition, new graduates are subjected to ethical tensions created by institutional constraints which can create dilemmas and uncertainties through practice that does not align with what they anticipated.

Understanding ethical tensions experienced by new graduates enables provision of informed support. There needs to be considerable cultural change for orientation and socialisation of new graduates to enable them to learn and manage ethical tensions.

Medical education literature suggests that ethics education should be learner-centered and problem-based rather than theory-based. Team-based learning is an appropriate method for this suggestion. However, its effectiveness was not investigated enough in medical ethics education.

Is team-based learning effective in medical ethics education in terms of knowledge retention, in-class learner engagement, and learner reactions?

This was a prospective controlled follow-up study. We changed lecture with team-based learning method to teach four topics in a 2-week medical ethics clerkship, while the remaining topics were taught by lectures. For comparison, we formed team-based learning and lecture groups, in which the students and instructor are the same, but the topics and teaching methodologies are different. We determined in-class learner engagement by direct observation and student satisfaction by feedback forms. Student success for team-based learning and lecture topics in the end-of-clerkship exam and two retention tests performed 1 year and 2 years later were compared.

Ethical approval for the study was granted by Akdeniz University Board of Ethics on Noninvasive Clinical Human Studies Ethics committee.

Short-term knowledge retention did not differ; however, team-based learning was found superior to lecture at long-term retention tests. Student satisfaction was high with team-based learning and in-class engagement was better in team-based learning sessions.

Our results on learner engagement and satisfaction with team-based learning were similar to those of previous reports. However, knowledge retention results in our study were contrary to literature. The reason might be the fact that students prepared for the end-of-clerkship pass/fail exam (short term) regardless of the teaching method. But, at long-term retention tests, they did not prepare for the exam and answered the questions just using the knowledge retained in their memories.

Our findings suggest that team-based learning is a better alternative to lecture to teach ethics in medical education.

The nature of children’s cancer comes with lots of ethical issues. Nurses are encouraged to adhere to ethical codes in their practice.

This study aimed to compare the perspectives of nurses and mothers of children with cancer regarding the adherence of nurses to ethical codes.

In this descriptive-comparative study, a researcher-made questionnaire was used to assess the amount of adherence to Iranian nurses’ code of ethics in perspectives of pediatric oncology nurses and mothers. As a convention, the total scores were categorized as optimal, average, and low adherence.

A total of 200 mothers and 60 nurses in pediatric oncology wards of five major hospitals in Tehran, Iran, participated in 2016.

Organizational approval by the university and informed consent were ensured before conducting the research. The principles of voluntariness, confidentiality, and anonymity were respected during the research process.

Results showed the mean score of the adherence to ethical codes by nurses, as per the nurses is 86.71 (12.57) and as per the mothers is 78.67 (16.09). The highest frequency for “Low adherence” and “Optimal adherence” to code of ethics by nurses were “Respect for individual autonomy and decision-making” (mothers, 72% and nurses, 70%) and “Commitment to confidentiality” (mothers, 64% and nurses, 74%), respectively. This revealed a significant difference between the responses of the nurses and the mothers (p = 0.001).

The results support the other studies in Iran about the difference between the perspectives of patients and nurses about adherence of nurses to ethical codes.

Integration of family-centered and conventional care in addition to more attention to the education of professional ethical principles could be helpful to improve the ethical performance of nurses in oncology pediatric wards.

An ethical, informed consent process requires that potential participants understand the study, their rights, and the risks and benefits. Yet, despite strategies to improve communication, many participants still lack understanding of potential risks and benefits. Investigating attitudes and practices of research nurses can identify ways to improve the informed consent process.

What are the attitudes, practices, and preparedness of nurses involved in the informed consent process regarding communication of risks and benefits?

A survey was developed and administered online to a national purposive sample of 107 research nurses with experience obtaining informed consent for clinical trials. Survey responses stratified by selected work-related characteristics were analyzed.

Participants were instructed they need not answer each question and could stop at any time. They consented by clicking “accept” on the email which linked to the survey. The study was approved by the Northeastern University Institutional Review Board, Boston, Massachusetts (NU-IRB Protocol #: 13-06-17).

Most research nurses (87%) used a teach-back method to assess participant comprehension, while 72% relied on their intuition. About one-third did not feel prepared to communicate related statistics. About 20% did not feel prepared to tailor information, and half did not feel competent using supplemental materials to enhance risks and benefits comprehension. Only 70% had received training in the informed consent process which included in-person training (84%), case studies (69%), online courses (57%), feedback during practice sessions (54%), and simulation, such as role playing (49%) and viewing videos (45%). Perceived preparedness was significantly associated with greater informed consent experience and training.

Research nurses may have inadequate training to encourage, support, and reinforce communication of risks and benefits during the informed consent process. Relevant purposeful education and training should help to improve and standardize the ethical informed consent process.