Increased technological and pharmacological interventions in patient care when patient outcomes are uncertain have been linked to the escalation in moral and ethical dilemmas experienced by health care providers in acute care settings. Health care research has shown that facilities that are able to attract and retain nursing staff in a competitive environment and provide high quality care have the capacity for nurses to process and resolve moral and ethical dilemmas. This article reports on the findings of a systematic review of the empirical literature (1980 - February 2007) on the effects of unresolved moral distress and poor ethical climate on nurse turnover. Articles were sought to answer the review question: Does unresolved moral distress and a poor organizational ethical climate increase nurse turnover? Nine articles met the criteria of the review process. Although the prevailing sentiment was that poor ethical climate and moral distress caused staff turnover, definitive answers to the review question remain elusive because there are limited data that confidently support this statement.

The aim of the present study was to investigate the association between work-related moral stress, moral climate and moral sensitivity in mental health nursing. By means of the three scales Hospital Ethical Climate Survey, Moral Sensitivity Questionnaire and Work-Related Moral Stress, 49 participants' experiences were assessed. The results of linear regression analysis indicated that moral stress was determined to a degree by the work place's moral climate as well as by two aspects of the mental health staff's moral sensitivity. The nurses' experience of 'moral burden' or 'moral support' increased or decreased their experience of moral stress. Their work-related moral stress was determined by the job-associated moral climate and two aspects of moral sensitivity. Our findings showed an association between three concepts: moral sensitivity, moral climate and moral stress. Despite being a small study, the findings seem relevant for future research leading to theory development and conceptual clarity. We suggest that more attention be given to methodological issues and developing designs that allow for comparative research in other disciplines, as well as in-depth knowledge of moral agency.

Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.

The responsibility for 'compassionate' care is a shared one. Nurses need to be cognizant of factors that are enabling or inhibiting their ability to be compassionate. Healthcare leaders have a responsibility to provide structural support (staffing, education and space) that assist nurses to deliver compassionate care and where appropriate cater for nurses needs so that they are better able to be compassionate.

Drawing on the Foucauldian concept of 'governmentality' to analyse the evidence-based movement in nursing, we argue that it is possible to identify the governance of nursing practice and hence nurses across two distinct axes; that of the political (governance through political and economic means) and the personal (governance of the self through the cultivation of the practices required by nurses to put evidence into practice). The evaluation of nursing work through evidence-based reviews provides detailed information that may enable governments to target and instruct nurses regarding their work in the interest of preserving the health of the population as a whole. Political governance of the nursing population becomes possible through centralised discursive mechanisms, such as evidence-based reviews that present nursing practice as an intelligible field whose elements are connected in a more or less systematic manner. The identity of the evidence-based nurse requires the modern nurse to develop new skills and attitudes. Evidence-based nursing is an emerging technology of government that judges nursing research and knowledge and has the capacity to direct nursing practice at both the political and personal level.

ObjectivesTo estimate the incidence, duration and cost of futile treatment for end-of-life hospital admissions.DesignRetrospective multicentre cohort study involving a clinical audit of hospital admissions.SettingThree Australian public-sector tertiary hospitals.ParticipantsAdult patients who died while admitted to one of the study hospitals over a 6-month period in 2012.Main outcome measuresIncidences of futile treatment among end-of-life admissions; length of stay in both ward and intensive care settings for the duration that patients received futile treatments; health system costs associated with futile treatments; monetary valuation of bed days associated with futile treatment.ResultsThe incidence rate of futile treatment in end-of-life admissions was 12.1% across the three study hospitals (range 6.0%–19.6%). For admissions involving futile treatment, the mean length of stay following the onset of futile treatment was 15 days, with 5.25 of these days in the intensive care unit. The cost associated with futile bed days was estimated to be $AA12.4 million for the three study hospitals using health system costs, and $A988 000 when using a decision maker’s willingness to pay for bed days. This was extrapolated to an annual national health system cost of $A153.1 million and a decision maker’s willingness to pay of $A12.3 million.ConclusionsThe incidence rate and cost of futile treatment in end-of-life admissions varied between hospitals. The overall impact was substantial in terms of both the bed days and cost incurred. An increased awareness of these economic costs may generate support for interventions designed to reduce futile treatments. We did not include emotional hardship or pain and suffering, which represent additional costs.

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Primary lay carers are increasingly important in the care of patients with cancer, but their role can be complex and extended. Potential carers may feel anything from highly committed to not at all interested in caregiving, but powerful social norms pressure them to accept the role, and reluctance may be hidden to avoid censure. The purpose of this review was to gain insights into caregiving reluctance and its consequences. The findings were organized into 4 major dimensions: demographic, physical, psychological, and social. Three major outcomes were identified: deterioration in the carer-patient relationship, reduced quality of care, and institutionalization. Definitive answers to the review questions remain elusive. Choice seems to be a major indicator of caregiving reluctance, although reluctance may not remain static over the caregiving trajectory. Caregiving reluctance remains an underexplored topic, particularly in the context of cancer.