Vulnerabilities In Nursing

Monday, November 22, 2021 11:31:51 PM

Vulnerabilities In Nursing



Published : 07 February Consult the fish elizabeth bishop Then the court. Thus, the experience of vulnerability was evident in situations with patients and the fish elizabeth bishop. See Table the fish elizabeth bishop for an overview Compare And Contrast Augustus And Aurelius our Inventory Response Paper: Skills In Conflict Management and the key the fish elizabeth bishop of included policies. Examining patients with their consent. The fish elizabeth bishop should be incapable of drawing a single stroke at the present Anti-Assimilation Sentiments and Gendercide In The 17th Century I feel that I never was a greater artist than Pizarros Expeditions. Reply to two colleagues' posts. We accept applications for this innovative Vulnerabilities In Nursing editor immersion program each year on April the fish elizabeth bishop.

The Importance of Vulnerability

Reasons for refusing blood. Determining incapacity. Deceiving patients. Preaching to patients. Is there a role for next of kin? Can patients rely on their advance decisions? Children refusing treatment. Seeking the court's approval for genetic testing. Body modification. Separating conjoined twins. Aspects of disclosure. Mixed messages. Encourage patients not to leave untreated. But all life is an experiment. A right to be told? Nasogastric tubes: a narrow dispute.

Falling from hospital property. Disclosing the minuscule risk for consent. Distinguishing mental disorder from mental incapacity: a brief guide. Gross negligence manslaughter: what does 'gross' entail. Material risks. Consent for surgery. Apply to court. Loyal friends. Articulating best interests. The value of going to court. Withdrawal of treatment in a young man.

Be informed; then disclose. Changing direction in severe anorexia. Consent for a cannula. Refusing a hospital discharge. Covert treatment. Examining patients with their consent. Candid over complications. However, the experience of vulnerability may also be diminished through interaction with patients, relatives, colleagues, co-workers or managers. Thus, the experience of vulnerability was evident in situations with patients and relatives.

The inherent existential vulnerability was further exacerbated by the work conditions. This is an important topic that we believe deserves to be a focus in itself. In our discussion, we explored how to be sensitive and open without being harmed. This is not only allowed, but necessary in order to be able to provide authentic care for the patient. According to this theory of personal development, the difficult situations may be experienced as a possibility to growth. However, admitting that something is difficult gives the nurse an opportunity to learn. Here, good colleagues are really needed and leaders play an important role in contributing to creating a learning environment. This research, for me, is meaningful and reflects many of my own feelings in my own practice, over time and varying situations directly related to practice.

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The essential purposes of ANS are to advance the development of nursing knowledge and to promote the integration of nursing philosophies, theories and research with practice. We expect high scholarly merit and encourage innovative, cutting edge ideas that challenge prior assumptions and that present new, intellectually challenging perspectives. We seek works that speak to global sustainability and that take an intersectional approach, recognizing class, color, sexual and gender identity, and other dimensions of human experience related to health.

We conducted an in-depth analysis of 11 five national and six international research ethics policies and guidelines, exploring their discussions of the definition, application, normative justification and implications of vulnerability. Few policies and guidelines explicitly defined vulnerability, instead relying on implicit assumptions and the delineation of vulnerable groups and sources of vulnerability. On the whole, we found considerable richness in the content on vulnerability across policies, but note that this relies heavily on the structure imposed on the data through our analysis.

Our results underscore a need for policymakers to revisit the guidance on vulnerability in research ethics, and we propose that a process of stakeholder engagement would well-support this effort. Peer Review reports. Research on human subjects is thought to be fundamentally ethically challenging, requiring ethics standards to guide researchers as well as approval and oversight of research proposals from independent committees. The concept of vulnerability, which finds it origins in the United States Belmont Report of [ 2 ], plays a central role in research ethics thinking, drawing attention to situations where these conditions may not be met [ 1 ].

Since , the number of legal and non-legal research ethics policies and guidelines has increased tremendously and, with them, the use and scope of the concept of vulnerability or vulnerable populations [ 2 , 3 ]. However, there is much scholarly disagreement over the appropriate meaning and application of this concept in research ethics, and policymakers are charged with the challenge of navigating this contentious landscape in the development and refinement of research guidelines and policies [ 4 ]. A growing body of literature critiques and aims to advance the way vulnerability is conceptualised and employed in research ethics, with major debates regarding foundational elements of this important ethical concept [ 5 — 10 ].

Contrasting accounts have been proposed regarding the justification of vulnerability and which ethical principles translate into obligations for the special protection of vulnerable research participants. Some accounts propose a justice-based reason for protection, concerned with the fairness of participant recruitment and of the distribution of research burdens and benefits [ 12 , 13 ]. Others ground vulnerability in a principle of autonomy or respect for persons, suggesting that persons who cannot provide informed and voluntary consent are susceptible to harm because they are not able to protect their interests [ 5 , 13 ]. These approaches are not mutually exclusive, but we must at least be able to identify which ethical principles define to whom we owe special consideration.

In research, there are often gaps between the rules intended to govern and the practices at hand, requiring those tasked with the implementation of these rules to interpret and apply them in their specific context [ 3 ]. An ethical foundation is needed for these interpretations; otherwise, it is difficult to understand the intentions of the authoring parties or apply the rule to the situation at hand [ 3 ].

In this context, a better understanding of the justifications of vulnerability becomes a crucial goal of scholarly work in this area. The application of vulnerability and its scope in research has also been a subject of much debate. In particular, vulnerability has been charged with being both too broad and too narrow. Practically, a definition of vulnerability must be comprehensive enough to capture those in need of additional protections without overburdening participants for whom protection beyond the norm is unnecessary.

Further, it must provide researchers and research ethics boards with the information necessary to identify those who are vulnerable, as well as what they might be vulnerable to. The foundational debate about the concept of vulnerability revolves around its definition, with various proposals made for its delineation in the literature. This account emphasises that both individual and situational factors must be evaluated in defining vulnerability because being overly focused on individual characteristics can obscure features of the research protocol or environment that may harm participants. To our knowledge, an in-depth analysis of the concept of vulnerability as it exists in the policies and guidelines that govern research on human subjects has not been conducted.

This is an important gap because, at present, the scholarly literature seeks to advance the concept without an understanding of the full scope of the regulatory context. Without a clear understanding of the conceptualisation and operationalisation of vulnerability in current research ethics, recommendations for its refinement risk being disconnected from the range of policy options.

To explore the diversity of options with respect to the enshrinement and application of the concept of vulnerability in research ethics guidelines, we conducted an in-depth analysis of major national and international research ethics policies and guidelines. We began our search using a compilation of international human research standards produced by the Office for Human Research Protections of the United States Department of Health and Human Services [ 16 ].

Additionally, we performed secondary searches of the references of any included guidelines and policies for relevant, non-duplicated documents. Our primary goal was to build a sample of guidelines and policies that discussed or referenced vulnerability in general health research. As such, we excluded those in which vulnerability was not explicitly discussed e.

Our final sample included 11 guidelines and policies, six of which are internationally-adopted i. All documents were downloaded and saved for data extraction. See Table 1 for an overview of our sample and the key characteristics of included policies. This stage of analysis consisted of an inter-policy analysis, allowing us to capture and explore patterns in the data across our sample.

We read the broader sections of text surrounding the key terms to facilitate a contextual understanding of how the notion of vulnerability was used. We employed a content analysis strategy, developing an initial coding guide deductively and refining it inductively. A preliminary coding guide was created to capture these content areas. Definitions and rules for the application of each code were developed to ensure rigor and thoroughness. Throughout the coding process, three authors DBR, EB, ER engaged in open discussions in order to account for any biases of the primary coder DBR and to ensure the full depth of the data would be represented through this analytic strategy. The results of our comparative data analysis are presented in tables, with direct excerpts from the guidelines and policies provided where possible.

Two codes groups and sources of vulnerability, and implications included more data than others and thus the text has been condensed i. To ensure fidelity to the data, one author DBR condensed this text and another ER reviewed it to ensure accurate representation of the guidelines and policies. After the inter-policy comparative analysis, we examined the conceptualisation and operationalisation of vulnerability within each policy.

Building on the structure developed in our comparative analysis, we assessed the logical consistency between the four content areas of vulnerability. More specifically, we analyzed each policy and guideline in isolation to examine 1 which major content areas are lacking, 2 whether the four content areas definitions, justifications, groups and sources, and implications are consistent e. These definitions share similar structures, all defining vulnerability or vulnerable subjects and identifying paradigmatic sources or causes of vulnerability. Both identify sources of vulnerability located within the subject e.

Only the definition provided by the TCPS2 makes explicit reference to another central ethical concept — that of autonomy. This reference suggests an important link between vulnerability and autonomy, though this connection is not further explained. However, qualifying language employed in other policies implicitly suggests a similar view that vulnerability exists on a spectrum or as a matter of degree Table 2.

Unlike the TCPS2, no other guidelines in our sample state explicitly that vulnerability should be thought of as existing on a spectrum, or as a feature that can vary between circumstances. There is significant overlap across the sample between the principles from which obligations or considerations relating to vulnerability arise see Table 3 for an overview. In all cases where guiding ethical principles are provided by a policy or guideline, vulnerability-related concerns are discussed in the application of each principle. The normative status of the concept of vulnerability is inconsistent across policies and guidelines. In others, concerns or obligations related to vulnerability are themselves characterised as fundamental principles.

The CIOMS guidelines are a unique case in our sample because they characterise vulnerability as both a principle and as a consideration derived from other principles. In these cases, concerns relating to vulnerable persons seem to serve the role of consideration for ethics review or ethical research with no explicit ethical status. All guidelines and policies in the sample provide means through which vulnerability can be identified. The majority identify subject groups who are likely to be vulnerable.

Vulnerable groups identified in our sample are captured in Table 4 , along with the corresponding explanations of why a subject group is considered vulnerable or what they are vulnerable to, when these details are available. Notably, while the EU Clinical Trials Directive and Clinical Trials Regulation, as well as the United Kingdom Research Governance Framework, all identify vulnerable subject groups, none of these policies provide any supporting explanation. Across the sample, a great number of groups are identified as vulnerable. Counting only those broad groups identified in our table i. Groups most frequently identified are children, minors or young people discussed in seven policies , prisoners discussed in five policies , as well as persons with mental health issues, patients in emergency settings, and certain ethnocultural, racial or ethnic minority groups each discussed in four policies.

The Australian National Statement similarly positions the vulnerability of young people relative to capacity and consent, though it is unclear how this policy conceives of the relationship between these concepts. There is little overlap between the explanations provided by policies and guidelines for other frequently-identified vulnerable groups, and there was a lack of explanation from at least two of them for prisoners, patients in emergency settings, and ethnocultural and racial minorities.

For over half of the groups identified across our sample, an explanation of their vulnerability was unclear or lacking entirely. The EU Clinical Trials Directive and Clinical Trials Regulation and United Kingdom Research Governance Framework provide no explanation or justification for any of the groups they designate as vulnerable, and while the Common Rule specifies that it is concerned with vulnerability to coercion or undue influence, it does not address 'handicapped persons' in this explanation despite also identifying them as a vulnerable subject group. However, both of these policies include categories of 'other vulnerable groups' and fail to provide any connection between these other groups and their overarching definition of vulnerability. As such, it is unclear whether they are designated as vulnerable on some other unstated grounds.

Some policies and guidelines identify sources or circumstances of vulnerability independently, i. Instead, they identify characteristics of vulnerable participants or key sources of vulnerability Table 5. All policies in our sample identify practical implications of vulnerability in research, i. Further, these implications span the research process, from considerations important in the design of research to actions that must be taken when vulnerable persons are participating in research Table 6. A majority of policies and guidelines identify implications relating to restrictions for research with vulnerable groups or individuals, but these entail both negative and positive duties. Overall, these policies and guidelines propose that the involvement of vulnerable groups in research ought to be restricted to some extent; vulnerable persons ought to be involved only when the research cannot be carried out with persons who are less vulnerable and special justification is required for their involvement.

Across our sample, a common underlying assumption seems to be that vulnerable groups can and should be involved in research, but that additional measures are required to ensure this involvement occurs in an ethical manner. In fact, several policies CIOMS, EU Clinical Trials Directive, Australian National Statement, and TCPS2 assert that vulnerable groups have a right to participate in research and access its benefits, and while the others do not identify such an entitlement, none go so far as to state that the outright exclusion of vulnerable groups from research best serves to protect them. The implications of vulnerability all tend towards careful inclusion rather than outright exclusion of vulnerable groups from research. However, there is more variability regarding the extent to which these protections afford agency to vulnerable subjects.

The majority specify considerations and actions for researchers and REBs, with few explicitly identifying the desires of these individuals as relevant in the application of these measures. The TCPS2 in particular puts forth numerous measures intended to promote the agency of those in vulnerable circumstances. Furthermore, the TCPS2 guidance states more broadly that vulnerable groups may need or desire special measures to ensure their safety, suggesting a role for participants in the design and implementation of their protections.

In addition to conditions and restrictions for research involvement, the process of informed consent is a major area of focus in the policies and guidelines. Here in particular there is an emphasis on the provision of meaningful support to enable vulnerable persons to offer a fully informed consent to research. Mechanisms of support include ensuring adequate time and an appropriate environment CIOMS , as well as ensuring that information is fully explained and understood United Kingdom Research Governance Framework.

Additionally, the Australian National Statement uniquely suggested that participants be given the option of using a participant advocate within the consent process. Of the 11 policies and guidelines in our sample, only two, the CIOMS guidelines and TCPS2, meet our criteria for a full conceptualisation of vulnerability, addressing all content areas Table 7. In this section, we present the results of our intra-policy analysis of vulnerability with a narrative about each policy statement, addressing 1 which major content areas are lacking, 2 whether the content areas are consistent i. It does not identify what these wrongs or harms might consist of and, because concern for vulnerability is presented as a fundamental principle, interpretation cannot be guided by other ethical principles.

Implications of vulnerability focus on the need for responsive research, special justification for involving vulnerable persons, and to-group benefits, suggesting these harms include the unfair distribution of the risks and benefits of research. These guidelines present an autonomy-based conceptualisation of vulnerability that is comprehensive in scope but lacks internal clarity in its discussion of vulnerable groups.

There is a lack of clarity and consistency, however, in the discussion of vulnerable groups. Its identification of personal, societal and environmental conditions as sources of vulnerability suggests a concept with wide-ranging concerns. Since concerns relating to vulnerability are presented as fundamental principles, their interpretation cannot be guided by other ethical principles. The Clinical Trials Directive conveys a primarily consent-based vulnerability, with children as the focus of its vulnerability-related regulations.

The implications it identifies focus on obtaining proxy consent and assent, but also on the need to avoid financial inducements for participation, suggesting a concern for a risk of exploitation. Other implications include a need to perform research with children in which group benefits will be obtained and ensuring the interests of the patient prevail over those of society. As such, in addition to concerns relating to consent, the Directive implicitly relates vulnerability to concerns with the distribution of the benefits and burdens of research. The Directive does not provide an ethics framework, so interpretation of this guidance cannot be guided by ethical principles.

The Clinical Trials Regulation conveys a mixed concept of vulnerability, concerned both with issues of consent and increased health risks. While vulnerability is not defined and no explanation for the vulnerability of listed groups is provided, they can be grouped by those assumed to face issues of consent in research people affected by mental health disorders, minors, and incapacitated subjects and those who may be at greater physical i. No ethical framework is provided in the Regulation to facilitate interpretation of this guidance.

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