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BACKGROUND: Attention to ethical leadership in nursing has diminished over the past several decades. OBJECTIVES: The aim of our study was to investigate how frontline nurses and formal nurse leaders envision ethical nursing leadership. RESEARCH DESIGN: Meta-ethnography was used to guide our analysis and synthesis of four studies that explored the notion of ethical nursing leadership. PARTICIPANTS AND RESEARCH CONTEXT: These four original studies were conducted from 1999-2008 in Canada with 601 participants. ETHICAL CONSIDERATIONS: Ethical approval from the original studies covered future analysis. FINDINGS: Using the analytic strategy of lines-of-argument, we found that 1) ethical nursing leadership must be responsive to practitioners and to the contextual system in which they and formal nurse leaders work, and 2) ethical nursing leadership requires receiving and providing support to increase the capacity to practice and discuss ethics in the day-to-day. DISCUSSION AND CONCLUSION: Formal nurse leaders play a critical, yet often neglected role, in providing ethical leadership and supporting ethical nursing practice at the point of patient care.

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Visual or aesthetic data can contribute to understanding experiences that may not be able to be fully understood through spoken or written words. This article describes stories of symbols that represent the experiences of individuals living with chronic kidney disease. Symbols included both objects (i.e., a family photograph) and intangible representations (i.e., apiece of music) that were chosen because they innately held meaning to the person. Descriptive themes of the symbols included hopes and inspirations, reflections on "who I am," and confrontations of illness. Participants' expressions through symbols were further described through the use of stories of memories, emotions, and poetic devices. We contend that symbols convey aspects of experience that cannot easily be translated into oral expression.

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This research explores perceptions regarding death and dying among people with chronic kidney disease. The methodology for the study was narrative inquiry informed by social constructivism. In-depth narrative interviews were conducted on two occasions with 14 participants. The participants included 10 men and 4 women (mean age of 66) who were treated in a mid-size Canadian city. Four themes relating to death and dying emerged from the data: awareness of death as a consequence of kidney failure, close calls, contemplation of suicide and/or withdrawal from dialysis, and preparing for death while living life. From the findings, it appeared that participants were very aware of the risk of dying from their illness, experienced serious health crises, and planned for their deaths. They were comfortable in discussing death and dying and acknowledged withdrawal from dialysis as an option.

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AIMS AND OBJECTIVES: To examine stories of spirituality in people living with serious illness. BACKGROUND: Although knowledge about the experience of people with various chronic illnesses is growing, there is little known about peoples' beliefs and perspectives relating to spirituality where there is a diagnosis of a serious chronic and life-limiting illness. DESIGN OF THE STUDY: A social constructionist approach to narrative inquiry was used. METHODS: In-depth narrative interviews were conducted on one occasion with 32 participants. This included 10 people with cancer, 14 people with end stage renal disease (ESRD) and eight people with HIV/AIDS. They ranged in age from 37-83 and included 18 men and 14 women. RESULTS: The themes were reflecting on spiritual religious and personal beliefs, crafting beliefs for their own lives, finding meaning and transcending beyond words. Participants melded various belief systems to fit their own lives. They also looked to find meaning in their illness experience and described what gave life meaning. For some aspects of these belief systems, participants could not or would not express themselves verbally, and it seemed that aspects of their experience were beyond language. CONCLUSIONS: The stories revealed considerable depth relating to perspectives on life, illness and existential questions, but many participants were not comfortable with the term 'spirituality'. RELEVANCE TO CLINICAL PRACTICE: Nurses must remain open to learning about belief systems of each individual in their care, regardless of that individual's declared religious affiliation or declaration of no religious affiliation, given that personal beliefs and practices do not always fit into specific categories.

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Nurses are frequently portrayed in the literature as being silent about ethical concerns that arise in their practice. This silence is often represented as a lack of voice. However, in our study, we found that nurses who responded to questions about moral distress were not so much silent as silenced. These nurses were enacting their moral agency by engaging in diverse, multiple and time-consuming actions in response to situations identified as morally distressing with families, colleagues, physicians, educators or managers. In many situations, they took action by contacting other healthcare team members, making referrals and coordinating care with other departments such as home care and hospice, as well as initiating contact with groups such as professional regulatory bodies or unions. Examining the relationship between ethical climate, moral distress and voice offers insights into both the meaning and impact of being silenced in the workplace.

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PURPOSE: To describe the relative importance of 38 facets of quality of life (QOL) to older adults in 22 countries, by gender, age group, and health status. METHODS: A secondary analysis of data was conducted from the WHOQOL-Old pilot study. Questionnaires were distributed by mail or in person. Independent t-tests for differences between means were calculated between importance scores by genders, age groups, and healthy/unhealthy participants. Hierarchical multiple regression analysis was used to identify which QOL facets explained importance of overall QOL. RESULTS ; Of 7,401 older adults from 22 countries (mean 73.1 years), 57.8% were women and 70.1% were 'healthy'. While there are significant differences in the importance of various facets of QOL on the basis of gender, age, and health status, when these variables were controlled in a stepwise multiple regression analysis, the most important QOL facets were having energy, being happy, having well-functioning senses, and being free from pain. CONCLUSION: It appears that many of the physical aspects of QOL such as energy, freedom from pain, ability to do activities of daily living and to move around are particularly important to older adults. Practitioners should give greater attention to energy, sensory abilities, and pain.

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In the current era of providing health care under pressure, considerable strain has been placed on nurses workplaces. Underneath the economic and organizational challenges prevalent in health-care delivery today are important values that shape the ethical climate in workplaces and affect the well-being of nurses, managers, patients and families. In this article, the authors report on the outcomes of Leadership for Ethical Policy and Practice, a three-year participatory action research study involving nurses, managers and other health-care team members in organizations throughout British Columbia. By using an ethics lens to look at problems, participants brought ethical concerns out into the open and were able to gain new insights and identify strategies for action to improve the ethical climate. Nurse leader support was essential for initiating and sustaining projects at six practice sites.

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Within Canada's fast-paced, ever-changing healthcare environment, providers are experiencing difficulty practising according to their professional ethical standards, leading many to experience moral or ethical distress. Limited attention has been paid to improvements in the ethical climate in healthcare settings in research focusing on nurses' workplaces. In this three-year study, we focused on how the ethical climate in healthcare delivery can be improved and how the use of participatory action research methods can lead to continued enhancements and lasting changes in services delivery. Together, we developed strategies for taking action, aimed at improving the quality of the work environment. This action involved both nurses in direct care and those in key leadership positions (CNOs or their equivalents). Through the active participation of those for whom the research-based change was intended, these strategies were tested in various sites across British Columbia and can be used as templates or designs for use in other settings. A key component of the success of the projects and action plans that were created was the integral involvement of nurse leaders through all phases.

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