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Although there is evidence to support nursing as a moral practice, there is no formula or dose to describe how much the nurse is obliged to risk in order to meet the ethical demand placed on him or her as a professional and to preserve the vulnerable trust essential to establish and maintain a therapeutic nurse-patient relationship. On the basis of research and significant statements from interviews with five participants, this article discusses examples of nurses’ moral responsibility stemming from knowledge of consciousness about the value of presence inherent in the relationship between nurse and patient. The challenge for the nurse is to understand that the trust and power embedded in his/her meeting with patients entails a demand for attentiveness and an ethical obligation to make changes from the stories shared by those who, through a disruption in life, find themselves in the presence of a nurse. IN THE SHADOW OF DEATH 2 The Online Journal of Health Ethics Volume 6, No. 1 July, 2010 In the Shadow of Death: A phenomenological study of the experiences of mid-life widows and the ethical implications for nurses. Introduction At the start of the 21 century, health care for women faces a number of critical challenges (Lee & Estes, 2003). As reported by Lee and Estes (2003) new data are challenging old ways of providing care and exposing large disparities in the health status of women. A woman’s health status is influenced by factors such as age, income, race/ethnicity and marital status. Employer-sponsored insurance is the predominant form of coverage for nonelderly women, with six in 10 covered by their own or their spouse’s employer. Each year nearly 10 million individuals in the United States will face the loss of their spouse, 69% of these being women. Wylie (1997) stated that the average age at which women become widowed is 56 and they remain spouseless for an average of 14 years (U.S. Bureau of the Census (1999)). More recent statistics reported by the 2006 U.S. Census indicated 32% of women aged 55 and older are widows; while 9% of men aged 55 and older are widowers. Although the average age falls just outside the middle age range (35-55), there is limited documented data available regarding this age group. Death of a spouse is described as one of the most stressful of all life events across all ages and cultural backgrounds. Kaslow (2004) describes the loss of a spouse for many individuals as one of the most tragic events that can occur. According to Holmes and Rahe (1967), bereavement increases stress and anxiety and can inhibit otherwise health-promoting behavior, thereby increasing negative health outcomes. Anxiety and stress in the bereaved is typified by decreased cognitive function, decreased problem-solving ability, inability to relax, and assumption of a hostile attitude (Lindermann, 1944). According to Kaslow (2004) even a IN THE SHADOW OF DEATH 3 The Online Journal of Health Ethics Volume 6, No. 1 July, 2010 different scenario may occur when someone is confronted with the sudden, instantaneous death of a partner. Parks & Weiss (1983) found that sudden unexpected death has been shown to have a debilitating effect on the bereaved in that shock acts to prolong grief, as well as to produce excessive physical and emotional traumas. Sanders (1980-1981) found that sudden death was such a shock that the capacity of the bereaved to cope was diminished greatly and full functioning was not recovered by some even four years following the death. Lundin (1984) describes participants who had experienced a sudden death and found they had more somatic and psychiatric illnesses, when compared to persons who had experienced an anticipated death. Miller and McGown (1997) discuss the variables of socioeconomic status, religiosity, stigmatic death and concurrent crisis as external mediators. Purpose The purpose of this article is to present results from a larger study (Williamson, 2010) and to propose new ethical guidelines based on the researcher’s experience with respondents. New guidelines are needed regarding middle-age women’s health and advocates are needed to bridge the work done on behalf of women’s health and bereavement after the sudden death of a spouse. The aim is to advocate for earlier connections in the nurse-patient relationship. Many studies have shown that the presence of a nurse practicing from the ethic of caring will encourage positive mental health. Raising awareness of bereavement care and support as a primary prevention health issue can, thereby reduce morbidity from unresolved grief and resulting health problems and can promote the quality of life for those facing major changes in their lives. Grief is not the total experience of the survival process for mid-life women who have lost their spouse to sudden death. Mistaking grief for the whole of the experience of any IN THE SHADOW OF DEATH 4 The Online Journal of Health Ethics Volume 6, No. 1 July, 2010 bereaved person is misleading because the experience is far more complex, entailing diverse emotional, physical, intellectual, spiritual, and social components. Background and Significance Issues surrounding dying and death raise many ethical concerns and questions for nurses as well as for the nursing profession. Many of these issues evoke a nurse’s personal feelings of ambiguity about death. Nurses should examine, individually and collectively, their own values in relation to death, quality of life, the importance of the individual needs of patients, and the caring dimensions of the nurse-patient relationship. The phenomena of concern to nurses in all practice settings are human experiences and responses and emotions to birth, health, illness, and death. Nurses focus on these phenomena within the context of individuals, families, groups, and communities. The nurse’s philosophical, theoretical and research-based understanding of these phenomena and the preferences of patients, families, or communities guide the formulation of plans of care. The American Nurses Association (ANA) in Nursing’s Social Policy Statement list the following values and assumptions which undergird professional nursing’s contract with society: 1. Humans manifest an essential unity of mind, body, and spirit. 2. Human experience is contextually and culturally defined. 3. Health and illness are human experiences. The presence of illness does not preclude health nor does optimal health preclude illness. 4. The relationship between nurse and patient involves participation of both in the process of care. 5. The interaction between nurse and patient occurs within the context of the values and beliefs of the patient and the nurse. 6. Public policy and the healthcare delivery system influence the health and well-being of society and professional nursing. These values and assumptions apply whether the recipient of professional nursing care is an individual, family, group, community, or population. The ANA emphasizes that it is IN THE SHADOW OF DEATH 5 The Online Journal of Health Ethics Volume 6, No. 1 July, 2010 important for nurses to integrate objective data of the physical (cellular to anatomical levels) with knowledge gained from an understanding of the client’s subjective experience. When nurses do not listen to the subjective experiences of patients, they are not practicing in an optimal healing environment as described by the ANA. The lived-experience is context-bound and best understood by a person’s perceptions (Benner, 1984). Perceptions are built upon one’s contextual experiences and come about through an awareness of one’s existential context (Benner, 1984; Munhall, 2007). An underlying assumption of the approach humans choose as they encounter events in their life-world, based on the works of Merleau-Ponty (1962) is that the situated individual co-creates and is created by temporal, environmental, and historical contexts. Scope of the Problem Placing middle aged women in the context of their life-world Burkhauser and Smeeding (1994) report eighty percent of all widows in poverty become poor only after their husbands die, and compared to men, elderly women are three times more likely to be widowed. Change in marital status and its subsequent effects were demonstrated by Shaw et al. who examined a group of women over a nine-year time span and found that poverty was relatively rare and did not increase among women who were married at both times in their study. Unfortunately, many of the fundamental political and economic structures that produce women’s poverty are attributable to the death of or divorce of the spouse. As nurses and nursing researchers reflected more on the bereavement experience of middle-age women, they began to question what it is that nurses do with the stories shared by these women. What connections do nurses make with the knowledge that they have gained from stories? What do nurses know about this experience? Maybe nurses do not listen to these women IN THE SHADOW OF DEATH 6 The Online Journal of Health Ethics Volume 6, No. 1 July, 2010 until there is a pathological change that brings them into the system. Do nurses ignore women’s stories of bereavement as part of their history? It is difficult to escape the realization that there are many things that nurses do not know, but there is a consuming desire to learn more about this experience as indicated in this research. Ethical Concerns for Research Vulnerable Groups Researchers should pay particular attention to the ethical dimensions of a study when people who are vulnerable are involved. Adherence to ethical standards is straightforward. The rights of special vulnerable groups, however, may need to be protected through additional procedures and heightened sensitivity on the part of the researcher. Vulnerable subjects are defined by Polit & Beck (2004) as a special group of people whose rights in studies need special protection because their circumstances place them at higher-than average risk

In The Shadow of Death: A Phenomenological Study of the Experiences of Mid-Life Widows and the Ethical Implications for Nurses