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Graduate Student Supervision
Doctoral Student Supervision (Jan 2008 - Nov 2019)
The definition of moral distress (MD) was put forward 35 years ago to explain the distress nurses felt when they experienced moral compromise. Making a moral judgment, enacting moral agency, and having constraints on agency have been identified as central to the experience. The known consequences of MD for health care professionals (HCPs), health care organizations, and patient care, are significant. Yet, researchers have struggled to develop meaningful interventions. The enactment of moral agency and constraints on agency are linked together in the experience. Constraints have been identified as being internal to the HCP, or external to the HCP and rooted in the context in which HCPs work. I argue that constraints on agency are dynamic (Musto & Rodney, 2016) and that gaining clarity on MD requires exploring the experience at the intersection of structure and agency. I engaged in this study to explore how HCPs navigated ethically challenging situations in complex acute mental health settings. I conducted this research using grounded theory (GT) methods. Grounded theory (GT) methodology allowed me to focus on the processes participants engaged in when they confronted ethical challenges. The study was multidisciplinary, conducted across two urban acute care mental health sites. I gathered data through semistructured interviews and observation. The basic social problem participants attempted to negotiate was systemic inhumanity, or the inability of the health care system to consistently extend respect, compassion, and dignity to individuals struggling with mental health issues. The resulting model, Risking Vulnerability: Enacting Moral Agency in the Is/Ought Gap, explains how participants were able to act as moral agents in the particular context they were embedded in. Participants negotiated ethical challenges relationally, by risking vulnerability; that is, holding their professional obligations, clinical expertise, and organizational processes in tension with their own vulnerability in the system. This study highlights the importance for organizations to create a relational space in which HCPs are safe to explore ethical questions about how policies and practices may dehumanize individuals struggling with mental health issues. Thereby contribute to conflicts between care that is actually given (Is) and care that aligns with professional moral obligations (Ought).
There is a growing awareness of inequities in rural healthcare in Canada and internationally. Rural nurses are embedded within complex healthcare structures, yet little attention has been paid to their experiences. These complex structures can function to both constrain and enable nurses to provide equitable, safe, and quality healthcare services to rural populations. This ethnographic study was conducted with rural nurses to explore the relationship between healthcare structures and rural nurses’ enactment of their agency. Informed by Structuration Theory (Giddens, 1984), Sewell’s (1992) notion of reciprocity, and a relational ethics lens, this research illuminates the relationship between the structures and rural nurses’ enactment of their agency in providing healthcare to rural based populations. Carspecken’s Critical Qualitative Research method (1996) was used to guide data collection during 528 hours of fieldwork and participant observations with primary nurse and allied healthcare provider participants (n=14). Additional data collected included: in-depth interviews (n=18); participant demographics; documents; and cultural commodities. Findings showed that the rural structure-nurse agent relationship was strained by urban-based policy-making. In particular, the rural practice context lacked sufficient physical and human resources to enact urban-policy directives (e.g. being unable to provide consistent primary and palliative care services). Nursing’s lack of active participation in policy decision-making has further impacted lack of policy directives toward fostering development of rural practice expertise. Key themes of: “we’re it”; “unseen complexity”; “pulling the nurse’s card”; “how many hands do you see?” and “beg forgiveness Monday morning” exemplified the disjuncture between rural and urban healthcare policy and practice. Inequities in access to healthcare services ultimately expanded rural nurses’ perceived moral obligations to include providing ad hoc care to the community outside of the formal system. Findings underscore that it is vital that rural nurses have an active voice in rural healthcare policy and decision-making in order to strengthen reciprocal relations and to provide equitable, safe, and ethical healthcare services for rural communities. Recommendations also include support for a nursing role in policy-making, increasing education opportunities, and expanding the scope of rural nursing practice to meet the demands of the rural practice context.
Increasingly, registered nurses (RNs)from lower income countries are seeking RN licensure and employment in Canada. Despite efforts to support their integration into the workplace, a significant number do not complete the registration process. To explore this phenomenon, using ethnographic methods informed by postcolonial feminism and relational ethical theory, I set out to learn from nurses educated in the Philippines about their experiences seeking RN licensure and employment in Canada. These nurses make up the greatest percentage of internationally educated nurses (IENs) in Canada and have a long history of migration to learn from. My goal was to understand how the experiences of these nurses shaped and were shaped by social, political, economic, and historical contexts and mediating oppressions at international, national, and local levels. Over the course of a year, I engaged 47 nurses in individual and focus group interviews. They had come to Canada with diverse immigration histories and work experiences. To enhance understanding of their perspectives I also collected data from secondary participants, such as nurse educators and immigration counselors, and reviewed immigration and regulatory documents. My analysis revealed that decisions at each stage of the nurse migration journey, which began in the Philippines and progressed to Canada, were not made in isolation. Rather, decisions were influenced by structures embedded within prevailing ideologies of neo-liberalism and neocolonialism and intersecting relations of gender, race, and class. Such structures and processes have the capacity to constrain agency and put nurses in jeopardy of marginalization, exploitation, and powerlessness. In this context, issues considered cultural might be better understood as partial and dynamic implications of broader social inequities. Consequently, it is imperative to extend our gaze beyond everyday practices of individual nurses, programs, and institutions and critically expose root causes of such inequities. Moreover, it is vital that the voices of IENs be included in health care planning and policy making.
Master's Student Supervision (2010 - 2018)
End of life conversations are challenging in all health care settings, and health care providers’ (HCPs) fears about holding end of life conversations are a barrier to quality patient centred care. This study explored HCPs’ experiences using a conversation “companion card” to structure end of life discussions and sought to understand HCPs’ experiences with goals of care (GOC) conversations.A theoretical perspective of relational ethics and a research methodology of Interpretive Description (ID) guided this research study. The methodology produced a qualitative description of experiences from a sample of HCPs. Over a two month period, the researcher gathered data during four semi-structured focus groups with twenty one participants at one urban acute care setting in Western Canada. In addition to focus groups the researcher relied on other processes to enhance her reflexivity, including journaling and memos; all of which are essential to ID inquiry. The findings of this study centre around four themes relating to participants’ experiences discussing GOC and the usefulness of the companion card in discussions. These themes are titled, the big struggle; responsibility; building relationships and the utility of the GOC companion card. Recommendations from this study addressed the need for research into the ethics of discussing GOC with patients and families with life limiting illnesses; organisational prioritisation ensuring therapeutic GOC discussions take place; incorporation of GOC discussions in educational programs across all health care sectors; and policy reform to ensure community care services can support ongoing GOC conversations.
No abstract available.