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Gramma R, Hanganu B, Arnaut O, Ioan BG. Potential Conflicts of Interest Arising from Dualism of Loyalty Imposed on Employees of Medical Institutions-Findings and Tools for Ethics Management. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1598. [PMID: 37763717 PMCID: PMC10536397 DOI: 10.3390/medicina59091598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Revised: 08/29/2023] [Accepted: 08/30/2023] [Indexed: 09/29/2023]
Abstract
Background and Objective: Doctors should have full loyalty to their patients, while patients should be able to trust that physicians will act only in their best interests. However, doctors may be faced with situations where they must choose between the patient's interests and those of a third party. This article presents the results of a study that aimed to identify situations of duality in the decision-making process of medical workers, which can compromise their ethical behavior. Materials and Methods: A cross-sectional study was carried out on a sample of 1070 participants, employed in 120 healthcare facilities in the Republic of Moldova. An online questionnaire was completed anonymously. Descriptive statistics for discrete data were performed by estimating absolute and relative frequencies. To perform the multivariate analysis, the logistic regression was applied. Results: A large number (74.4%) of respondents admitted that they had faced situations of conflicts of interest. Every third respondent (35.3%) had experienced ethical dilemmas when access to expensive treatments should be ensured. Every fourth respondent experienced a conflict between the patient's interests and those of the institution (26.1%) or the insurance company (23.3%). As age increases, the probability of reporting the dilemma decreases. Physicians reported such dilemmas almost 3 times more often than nurses. A low rate of staff sought support when faced with dilemmas. Half of the respondents (50.6%) preferred to discuss the problem only with a colleague, and 40.1% preferred to find solutions without anyone's help. There were significant gaps within organizations in terms of the ethical dimension of the decision-making process. Conclusions: Managers should adopt clear institutional policies and tools to identify and prevent situations of dual loyalty. Ethical support should be offered to employees facing such situations. The need to promote an institutional climate based on trust and openness becomes evident.
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Affiliation(s)
- Rodica Gramma
- Doctoral School, State University of Medicine and Pharmacy Nicolae Testemițanu, 2004 Chisinau, Moldova; (R.G.); (O.A.)
| | - Bianca Hanganu
- 3rd Medical Sciences Department, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
| | - Oleg Arnaut
- Doctoral School, State University of Medicine and Pharmacy Nicolae Testemițanu, 2004 Chisinau, Moldova; (R.G.); (O.A.)
| | - Beatrice Gabriela Ioan
- 3rd Medical Sciences Department, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iasi, Romania;
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2
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Wälivaara BM, Zingmark K. Descriptions of long-term impact from inter-professional ethics communication in groups. Nurs Ethics 2023; 30:614-625. [PMID: 36920799 PMCID: PMC10637078 DOI: 10.1177/09697330231160007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
BACKGROUND On a daily basis, healthcare professionals deal with various ethical issues and it can be difficult to determine how to act best. Clinical ethics support (CES) has been developed to provide support for healthcare professionals dealing with complex ethical issues. A long-term perspective of participating in inter-professional dialogue and reflective-based CES sessions is seemingly sparse in the literature. RESEARCH AIM The aim was to describe experiences of impact of Inter-professional Ethics Communication in groups (IEC) based on Habermas' theory of communicative actions, after 6 months from the perspective of an inter-professional team. RESEARCH DESIGN A qualitative inductive approach was chosen, and individual interviews (n = 13) were conducted. Interview data were analysed using qualitative content analysis. PARTICIPANTS The participants, 10 females and two males, represented assistant nurses, registered nurses, physicians, occupational therapists, physiotherapists, welfare officers and psychologists. Each had attended at least four IEC sessions. ETHICAL CONSIDERATIONS The study was approved by the Regional Ethical Review Board in Umeå, Sweden, and it has been undertaken in accordance with the Helsinki Declaration. FINDINGS Overall, the descriptions expressed a perceived achievement of a deepened and integrated ethical awareness that increased the participants' awareness of ethically difficult situations as well as their own ethical thinking, actions and approaches in daily work. Perspectives were shared and the team become more welded. They carried the memories of the reflections within them, which was perceived as supportive when encountered new ethically situations. DISCUSSION Putting words to unarticulated thoughts may stimulate repeated reflections, leading to new insights and alternative thoughts. CONCLUSION The outcome of IEC sessions 6 months following the last session can be described as an incorporated knowledge that enables actions in ethically difficult situations based on an ethical awareness both at a 'We-level' and an 'I-level'.
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What outcomes of moral case deliberations are perceived important for healthcare professionals to handle moral challenges? A national cross-sectional study in paediatric oncology. BMC Med Ethics 2022; 23:108. [DOI: 10.1186/s12910-022-00851-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 10/27/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In paediatric oncology, healthcare professionals face moral challenges. Clinical ethics support services, such as moral case deliberation (MCD), aim to assist them in dealing with these challenges. Yet, healthcare professionals can have different expectations and goals related to clinical ethics support services.
Methods
In this study, the perceptions held by healthcare professionals (nursing assistants, registered nurses, physicians, and others) regarding the importance of possible outcomes of MCDs, prior to implementation of MCDs, were investigated. A multisite, cross-sectional, quantitative study was performed at all six Paediatric Oncology Centres in Sweden. Healthcare professionals answered the Euro-MCD instrument with 26 potential MCD outcomes using a scale from Not important (1) to Very important (4). Descriptive and comparative statistical analyses were carried out.
Results
All outcomes were rated high, i.e., between 3.12 and 3.78. More open communication, developing skills to analyse ethically difficult situations, better mutual understanding, and deciding on concrete actions were rated as most important. Understanding of ethical theories and critical examination of policies were rated less important. Most often nursing assistants rated higher and physicians lower than the other professions did. Women and participants without previous experience of MCDs perceived outcomes as more important. There were differences between centres as one centre had significantly higher, and one centre had significantly lower ratings compared to the others.
Conclusion
It is clear that healthcare professionals want MCDs to improve teamwork and skills in order to analyse and manage ethically difficult situations. When comparing to previous research about important MCD outcomes, there were similarities in what healthcare professionals consider to be important when handling moral challenges regardless of country and potential differences in healthcare settings and systems, such as paediatric vs. adult care.
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Eijkholt M, de Snoo-Trimp J, Ligtenberg W, Molewijk B. Patient participation in Dutch ethics support: practice, ideals, challenges and recommendations-a national survey. BMC Med Ethics 2022; 23:62. [PMID: 35733137 PMCID: PMC9219170 DOI: 10.1186/s12910-022-00801-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 05/20/2022] [Indexed: 11/12/2022] Open
Abstract
Background Patient participation in clinical ethics support services (CESS) has been marked as an important issue. There seems to be a wide variety of practices globally, but extensive theoretical or empirical studies on the matter are missing. Scarce publications indicate that, in Europe, patient participation in CESS (fused and abbreviated hereafter as: PP) varies from region to region, and per type of support. Practices vary from being non-existent, to patients being a full conversation partner. This contrasts with North America, where PP seems more or less standard. While PP seems to be on the rise in Europe, there is no data to confirm this. This study sought a deep understanding of both habits and the attitudes towards PP in the Netherlands, including respondents’ practical and normative perspectives on the matter. Methods and Results We developed a national survey on PP for Dutch CESS staff. Our survey comprised a total of 25 open and close-ended questions, focused on four topics related to PP (1) goals of CESS, (2) status quo of PP, (3) ideas and ideals concerning PP, and (4) obstacles for PP. Discussion The four most important findings were that: (1) Patient participation in Dutch CESS is far from standard. (2) Views on patient participation are very much intertwined with the goals of ethics support. (3) Hesitations, fears and perceived obstacles for PP were not on principle and (4) Most respondents see PP as a positive opportunity, yet requiring additional training, practical guidance and experience. Conclusions Various normative reasons require PP. However, PP seems far from standard and somewhat rare in Dutch CESS settings. Our respondents did not raise many principled objections to PP. Instead, reasons for the lack of PP are intertwined with viewpoints on the goals of CESS, which seemingly focus on supporting health care professionals (HCPs). Training and practical guidance was thought to be helpful for gaining experience for both CESS staff and HCPs.
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Affiliation(s)
- Marleen Eijkholt
- Department of Medical Ethics and Health Law, Leiden University Medical Centre, Albinusdreef 2, 2333 ZA, Leiden, Netherlands.
| | | | - Wieke Ligtenberg
- Department of Ethics, Law and Humanities, Amsterdam UMC, Amsterdam, Netherlands
| | - Bert Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, Amsterdam, Netherlands
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5
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Metselaar S, van Schaik M, Widdershoven G. CURA: A clinical ethics support instrument for caregivers in palliative care. Nurs Ethics 2022; 29:1562-1577. [PMID: 35622018 PMCID: PMC9667086 DOI: 10.1177/09697330221074014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This article presents an ethics support instrument for healthcare professionals
called CURA. It is designed with a focus on and together with nurses and nurse
assistants in palliative care. First, we shortly go into the background and the
development study of the instrument. Next, we describe the four steps CURA
prescribes for ethical reflection: (1) Concentrate, (2) Unrush, (3) Reflect, and
(4) Act. In order to demonstrate how CURA can structure a moral reflection among
caregivers, we discuss how a case was discussed with CURA at a psychogeriatric
ward of an elderly care home. Furthermore, we go into some considerations
regarding the use of the instrument in clinical practice. Finally, we focus on
the need for further research on the effectiveness and implementation of
CURA.
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Affiliation(s)
- Suzanne Metselaar
- Suzanne Metselaar, Department of Ethics,
Law & Humanities, Amsterdam University Medical Centers, De Boelelaan 1089a,
Amsterdam 1081 HV, The Netherlands.
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6
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de Snoo-Trimp JC, van Gurp JLP, Molewijk AC. Conceptualizing the impact of moral case deliberation: a multiple-case study in a health care institution for people with intellectual disabilities. BMC Med Ethics 2022; 23:10. [PMID: 35120509 PMCID: PMC8817498 DOI: 10.1186/s12910-022-00747-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background As moral case deliberations (MCDs) have increasingly been implemented in health care institutions as a form of ethics support, it is relevant to know whether and how MCDs actually contribute to positive changes in care. Insight is needed on what actually happens in daily care practice following MCD sessions. This study aimed at investigating the impact of MCD and exploring how ‘impact of MCD’ should be conceptualized for future research. Methods A multiple-case study was conducted in a care organization for people with intellectual disabilities and/or acquired brain injury, by observing MCD sessions as ‘cases’, followed by interviews with health care professionals concerning the follow-up to these cases, and a focus group with involved MCD facilitators. A conceptual scheme concerning the possible impact formed the basis for analysis: (1) individual moral awareness; (2) the actions of health care professionals; (3) collaboration among health care professionals; (4) the concrete situation of the client; (5) the client’s quality of care and life; (6) the organizational and policy level. Results According to interviewees, their moral awareness and their collaboration, both among colleagues and with clients’ relatives, improved after MCD. Perceived impact on client situation, quality of care/life and the organizational level varied among interviewees or was difficult to define or link to MCD. Three aspects were added to the conceptual scheme concerning the impact of MCD: (a) preparations and expectations prior to the MCD session; (b) a translational step between the conclusions of the MCD session and practical events in the following period, and (c) collaboration with clients’ relatives. A negative impact of MCD was also found on misunderstandings among participants and disappointment about lack of follow-up. Conclusions Concretizing and conceptualizing the ‘impact’ of MCD is complicated as many factors play a role either before or during the transition from MCD to practice. It is important to consider ‘impact’ in a broad sense and to relate it to the goals and context of the MCD in question. Future studies in this field should pay additional attention to the preparations, content and process involved in ethics support, including clients’ and relatives’ experiences. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-022-00747-2.
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Affiliation(s)
- J C de Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, De Boelelaan 1089a, 1081 HV, Amsterdam, The Netherlands.
| | - J L P van Gurp
- Department IQ Healthcare, Radboud University Medical Center, Nijmegen, The Netherlands
| | - A C Molewijk
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, Amsterdam, The Netherlands.,Center of Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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7
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Weiner C, Pergert P, Molewijk B, Castor A, Bartholdson C. Perceptions of important outcomes of moral case deliberations: a qualitative study among healthcare professionals in childhood cancer care. BMC Med Ethics 2021; 22:27. [PMID: 33731101 PMCID: PMC7970765 DOI: 10.1186/s12910-021-00597-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 03/04/2021] [Indexed: 11/29/2022] Open
Abstract
Background In childhood cancer care, healthcare professionals must deal with several difficult moral situations in clinical practice. Previous studies show that morally difficult challenges are related to decisions on treatment limitations, infringing on the child's integrity and growing autonomy, and interprofessional conflicts. Research also shows that healthcare professionals have expressed a need for clinical ethics support to help them deal with morally difficult situations. Moral case deliberations (MCDs) are one example of ethics support. The aim of this study was to describe the MCD-related outcomes that healthcare professionals in childhood cancer care considered important, before MCDs were implemented, in order to facilitate the implementation of MCDs in childhood cancer care in Sweden.
Methods This study is based on qualitative data. Healthcare professionals, mostly representing registered nurses, nursing assistants and physicians, working at childhood cancer care centres in Sweden, were invited to respond to the translated and content validated European MCD Outcomes Instrument, before participating in regular MCDs. Answers to the main open-ended question, included in the questionnaire, was analysed according to systematic text condensation. Results Data was collected from 161 responses from the healthcare professionals. The responses included healthcare professionals’ perceptions of which MCD-related outcomes they found important for handling moral challenges. Three different themes of important outcomes from the analysis of the data are presented as follows: Interprofessional well-being in team interactions on a team level; Professional comfort when dealing with moral challenges on a personal level; and Improved quality of care for the child and the family on a care level. Conclusions Healthcare professionals in childhood cancer care considered it important that ethics support could enhance the well-being of interprofessional teams, support healthcare professionals on an individual level and improve quality of care. The results of this study can be used in current and future training for MCD-facilitators. When knowing the context specific important MCD-outcomes, the sessions could be adapted. Managers in childhood cancer care would benefit from knowing about the specific important outcomes for their target group because they could then create relevant working conditions for clinical ethics support.
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Affiliation(s)
- Charlotte Weiner
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Paediatric Regional Health Care, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Pernilla Pergert
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden.,Paediatric Haematology and Oncology, Astrid Lindgren Children's Hospital, Stockholm, Sweden
| | - Bert Molewijk
- Department of Medical Humanities, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands.,Center for Medical Ethics, University of Oslo, Oslo, Norway
| | - Anders Castor
- Paediatrics, Lund University, Lund, Sweden.,Pediatric Oncology, Hematology, Immunology and Nephrology, Skåne University Hospital, Lund, Sweden
| | - Cecilia Bartholdson
- Childhood Cancer Research Unit, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden. .,Paediatric Neurology and Musculoskeletal Disorders and Homecare, Astrid Lindgren Children's Hospital, Stockholm, Sweden.
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8
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Fischer-Grönlund C, Brännström M, Zingmark K. The 'one to five' method - A tool for ethical communication in groups among healthcare professionals. Nurse Educ Pract 2021; 51:102998. [PMID: 33639607 DOI: 10.1016/j.nepr.2021.102998] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 11/24/2022]
Abstract
Healthcare professionals have expressed a wish for facilitated inter-professional communications about ethical difficulties experienced in clinical practice. The introduction of an easily accessible method for facilitating ethical communication in groups may promote its implementation in everyday clinical practice. The aim of this paper was to draw on previous studies and available knowledge in order to develop and describe a method that enables systematic implementation of inter-professional ethical communication in groups. The 'one-to-five method' for facilitated ethical communication in groups is theoretically inspired by Habermas's theory of communicative actions and base on previous studies that accords with the Helsinki Declaration (2013). The 'one to five method' supports guidance of ethical communication in five steps: telling the story about the situation; reflections and dialogue concerning the emotions involved; formulation of the problem/dilemma; analysis of the situation and the dilemma; and searching for a choice of action or approach. It offers an easily accessible method for teaching healthcare professionals how to facilitate ethics communication groups. Educating facilitators closely connected to clinical work may lead to ethical dialogue becoming a natural part of clinical practice for healthcare professionals.
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Affiliation(s)
| | | | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology, Sweden.
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9
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Brännström M, Fischer Grönlund C, Zingmark K, Söderberg A. Meeting in a ‘free-zone’: Clinical ethical support in integrated heart-failure and palliative care. Eur J Cardiovasc Nurs 2019; 18:577-583. [DOI: 10.1177/1474515119851621] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Integrating heart-failure and palliative care combines expertise from two cultures, life-saving cardiology and palliative care, and involves ethically difficult situations that have to be considered from various perspectives. We found no studies describing experiences of clinical ethical support (CES) in integrated cardiology and palliative care teams. Objective: Our aim is to describe experiences of CES among professionals after a period of three years working in a multidisciplinary team in integrated heart-failure and palliative homecare. Method: The study design was descriptive qualitative, comprising interviews with seven professionals from one integrated heart-failure and palliative care team who received CES over a three-year period. The interview data were subjected to qualitative content analysis. Results: The CES was found to offer possibilities for meeting in an ethical ‘free-zone’ where the participants could relate to each other beyond their various professional roles and specialties. The trust within the team seemed to increase and the participants were confident enough to express their points of view. Together they developed an integrated understanding, and acquired more knowledge and a comprehensive view of the ethically difficult situation of concern. The CES sessions were considered a means of becoming better prepared to deal with ethical care issues and developing action strategies to apply in practice, from shared standpoints. Conclusion: Participating in CES was experienced as meeting in an ethical ‘free-zone’ and seemed to be a means of facilitating integration of palliative and heart-failure care.
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Affiliation(s)
- Margareta Brännström
- Department of Nursing, Umeå University, Sweden
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden
| | | | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology & Norrbotten County Council, Sweden
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10
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Grönlund CF, Söderberg A, Dahlqvist V, Sandlund M, Zingmark K. Communicative and organizational aspects of clinical ethics support. J Interprof Care 2018; 33:724-733. [PMID: 30497309 DOI: 10.1080/13561820.2018.1551862] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Studies show that healthcare professionals need inter-professional clinical ethics support (CES) in order to communicate and reflect on ethically difficult care situations that they experience in their clinical practice. Internationally, various CES interventions have been performed, but the communication processes and organisation of these interventions are rarely described in detail. The aim of this study was to explore communicative and organisational conditions of a CES intervention with the intention of promoting inter-professional communication about ethically difficult care situations. Eight audio- and video-recorded inter-professional CES sessions, inspired by Habermas' theory of communicative actions, were conducted. The observations were transcribed, sorted, and analysed using concept- and data-driven content analysis methods. The findings show three approaches to promoting communicative agreement, which include the CES facilitators' and participants' approaches to promoting a permissive communication, extended views, and mutual understanding. The CES sessions had organizational aspects for facilitating communicative agreement with both a given structure and openness for variation. The dynamic structure of the organization, promoted both safety and stability as well as a creativity and responsiveness, which in turn opened up for a free and dynamic inter-professional dialogue concerning ethically difficult care situations. The findings constitute a step towards a theory-based CES method inspired by Habermas' theory of communicative action. Further research is needed in order to fully develop the method and obtain increased knowledge about how to promote an inter-professional dialogue about ethically difficulties.
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Affiliation(s)
| | | | - Vera Dahlqvist
- Department of Nursing, Ersta Sköndal University College, Stockholm, Sweden
| | - Mikael Sandlund
- Department of Clinical Science/Psychiatry, Umeå University, Umeå, Sweden
| | - Karin Zingmark
- Department of Health Science, Division of Nursing, Luleå University of Technology & Norrbotten County Council, Luleå, Sweden
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Seekles W, Widdershoven G, Robben P, van Dalfsen G, Molewijk B. Inspectors' ethical challenges in health care regulation: a pilot study. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2017; 20:311-320. [PMID: 28130719 PMCID: PMC5569140 DOI: 10.1007/s11019-016-9736-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
There is an increasing body of research on what kind of ethical challenges health care professionals experience regarding the quality of care. In the Netherlands the Dutch Health Care Inspectorate is responsible for monitoring and regulating the quality of health care. No research exists on what kind of ethical challenges inspectors experience during the regulation process itself. In a pilot study we used moral case deliberation as method in order to reflect upon inspectors' ethical challenges. The objective of this paper is to give an overview of the ethical challenges which health care inspectors encounter in their daily work. A thematic qualitative analysis was performed on cases (n = 69) that were collected from health care inspectors in a moral case deliberation pilot study. Eight themes were identified in health care regulation. These can be divided in two categories: work content and internal collaboration. The work of the health care inspectorate is morally loaded and our recommendation is that some form of ethics support is provided for health care inspectors.
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Affiliation(s)
- W Seekles
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
- University of Humanistic Studies, Kromme Nieuwegracht 29, 3512 HD, Utrecht, The Netherlands.
| | - G Widdershoven
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - P Robben
- The Health Care Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - G van Dalfsen
- The Health Care Inspectorate (IGZ), Stadsplateau 1, 3521 AZ, Utrecht, The Netherlands
| | - B Molewijk
- Medical Humanities, VU University Medical Centre (EMGO+), Van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
- Centre for Medical Ethics, HELSAM, University of Oslo, Forskningsveien 3A, 0373, Oslo, Norway
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12
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Spronk B, Stolper M, Widdershoven G. Tragedy in moral case deliberation. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2017; 20:321-333. [PMID: 27913914 PMCID: PMC5569132 DOI: 10.1007/s11019-016-9749-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
In healthcare practice, care providers are confronted with tragic situations, in which they are expected to make choices and decisions that can have far-reaching consequences. This article investigates the role of moral case deliberation (MCD) in dealing with tragic situations. It focuses on experiences of care givers involved in the treatment of a pregnant woman with a brain tumour, and their evaluation of a series of MCD meetings in which the dilemmas around care were discussed. The study was qualitative, focusing on the views and experiences of the participants. A case study design is used by conducting semi-structured interviews (N = 10) with health care professionals who both played a role in the treatment of the patient and attended the MCD. The results show that MCD helps people to deal with tragic situations. An important element of MCD in this respect is making explicit the dilemma and the damage, demonstrating that there is no simple solution. MCD prompts participants to formulate and share personal experiences with one another and thus helps to create a shared perception of the situation as tragic. The article concludes that MCD contributes to the sharing of tragic experiences, and fosters mutual interaction during a tragedy. Its value could be increased through explicit reflection on the aspect of contingency that characterises tragedy.
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Affiliation(s)
- Benita Spronk
- VU Medisch Centrum, De Boelelaan 1117, Postbus 7057, 1007 MB, Amsterdam, The Netherlands.
| | - Margreet Stolper
- Metamedica, De Boelelaan 1089 a, F-vleugel/Medische Faculteit, 1081 HV, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Metamedica, De Boelelaan 1089 a, F-vleugel/Medische Faculteit, 1081 HV, Amsterdam, The Netherlands
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13
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Grönlund CF, Dahlqvist V, Zingmark K, Sandlund M, Söderberg A. Managing Ethical Difficulties in Healthcare: Communicating in Inter-professional Clinical Ethics Support Sessions. HEC Forum 2017; 28:321-338. [PMID: 27147521 DOI: 10.1007/s10730-016-9303-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Several studies show that healthcare professionals need to communicate inter-professionally in order to manage ethical difficulties. A model of clinical ethics support (CES) inspired by Habermas' theory of discourse ethics has been developed by our research group. In this version of CES sessions healthcare professionals meet inter-professionally to communicate and reflect on ethical difficulties in a cooperative manner with the aim of reaching communicative agreement or reflective consensus. In order to understand the course of action during CES, the aim of this study was to describe the communication of value conflicts during a series of inter-professional CES sessions. Ten audio- and video-recorded CES sessions were conducted over eight months and were analyzed by using the video analysis tool Transana and qualitative content analysis. The results showed that during the CES sessions the professionals as a group moved through the following five phases: a value conflict expressed as feelings of frustration, sharing disempowerment and helplessness, the revelation of the value conflict, enhancing realistic expectations, seeing opportunities to change the situation instead of obstacles. In the course of CES, the professionals moved from an individual interpretation of the situation to a common, new understanding and then to a change in approach. An open and permissive communication climate meant that the professionals dared to expose themselves, share their feelings, face their own emotions, and eventually arrive at a mutual shared reality. The value conflict was not only revealed but also resolved.
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Affiliation(s)
| | - Vera Dahlqvist
- Department of Nursing, Ersta Sköndal University College, P.O. Box 111 89, 100 61, Stockholm, Sweden
| | - Karin Zingmark
- Division of Nursing, Department of Health Science, Luleå University of Technology, 971 87, Luleå, Sweden.,Norrbotten County Council, Landstingshuset, 971 89, Luleå, Sweden
| | - Mikael Sandlund
- Department of Clinical Science/Psychiatry, Umeå University, 901 87, Umeå, Sweden
| | - Anna Söderberg
- Department of Nursing, Umeå University, 901 87, Umeå, Sweden
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Spijkerboer RP, van der Stel JC, Widdershoven GAM, Molewijk AC. Does Moral Case Deliberation Help Professionals in Care for the Homeless in Dealing with Their Dilemmas? A Mixed-Methods Responsive Study. HEC Forum 2016; 29:21-41. [PMID: 27535674 DOI: 10.1007/s10730-016-9310-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Health care professionals often face moral dilemmas. Not dealing constructively with moral dilemmas can cause moral distress and can negatively affect the quality of care. Little research has been documented with methodologies meant to support professionals in care for the homeless in dealing with their dilemmas. Moral case deliberation (MCD) is a method for systematic reflection on moral dilemmas and is increasingly being used as ethics support for professionals in various health-care domains. This study deals with the question: What is the contribution of MCD in helping professionals in an institution for care for the homeless to deal with their moral dilemmas? A mixed-methods responsive evaluation design was used to answer the research question. Five teams of professionals from a Dutch care institution for the homeless participated in MCD three times. Professionals in care for the homeless value MCD positively. They report that MCD helped them to identify the moral dilemma/question, and that they learned from other people's perspectives while reflecting and deliberating on the values at stake in the dilemma or moral question. They became aware of the moral dimension of moral dilemmas, of related norms and values, of other perspectives, and learned to formulate a moral standpoint. Some experienced the influence of MCD in the way they dealt with moral dilemmas in daily practice. Half of the professionals expect MCD will influence the way they deal with moral dilemmas in the future. Most of them were in favour of further implementation of MCD in their organization.
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Affiliation(s)
- R P Spijkerboer
- Faculty of Social Science and Applied Psychology, Leiden University of Applied Science, Post box 382, 2300AJ, Leiden, The Netherlands.
| | - J C van der Stel
- Faculty of Social Science and Applied Psychology, Leiden University of Applied Science, Post box 382, 2300AJ, Leiden, The Netherlands
| | - G A M Widdershoven
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VUmc Amsterdam, Postbox 7057, 1007 MB, Amsterdam, The Netherlands
| | - A C Molewijk
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VUmc Amsterdam, Postbox 7057, 1007 MB, Amsterdam, The Netherlands.,Centre for Medical Ethics, University of Oslo (UIO), Oslo, Norway
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Abstract
BACKGROUND Palliative carers constantly face ethical problems. There is lack of organised support for the carers to handle these ethical problems in a consistent way. Within organisational ethics, we find models for moral deliberation and for developing organisational culture; however, they are not combined in a structured way to support carers' everyday work. RESEARCH OBJECTIVE The aim of this study was to describe ethical problems faced by palliative carers and develop an adapted organisational set of values to support the handling of these problems. RESEARCH DESIGN Ethical problems were mapped out using focus groups and content analysis. The organisational culture were developed using normative analysis and focus group methodology within a participatory action research approach. Main participants and research context: A total of 15 registered nurses and 10 assistant nurses at a palliative unit (with 19 patient beds) at a major University Hospital in Sweden. Ethical considerations: The study followed standard ethics guidelines concerning informed consent and confidentiality. FINDINGS We found six categories of ethical problems (with the main focus on problems relating to the patient's loved ones) and five categories of organisational obstacles. Based on these findings, we developed a set of values in three levels: a general level, an explanatory level and a level of action strategies. DISCUSSION The ethical problems found corresponded to problems in other studies with a notable exception, the large focus on patient loved ones. The three-level set of values is a way to handle risks of formulating abstract values not providing guidance in concrete care voiced in other studies. CONCLUSION Developing a three-level set of values adapted to the specific ethical problems in a concrete care setting is a first step towards a better handling of ethical problems.
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Affiliation(s)
- Lars Sandman
- University of Borås, Sweden; Linköping University, Sweden.,University of Gothenburg, Sweden; Sahlgrenska University Hospital, Sweden
| | - Ulla Molander
- University of Gothenburg, Sweden; Sahlgrenska University Hospital, Sweden
| | - Inger Benkel
- University of Gothenburg, Sweden; Sahlgrenska University Hospital, Sweden
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Metselaar S, Molewijk B, Widdershoven G. Beyond recommendation and mediation: moral case deliberation as moral learning in dialogue. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2015; 15:50-51. [PMID: 25562230 DOI: 10.1080/15265161.2014.975381] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Silén M, Ramklint M, Hansson MG, Haglund K. Ethics rounds: An appreciated form of ethics support. Nurs Ethics 2014; 23:203-13. [PMID: 25527354 DOI: 10.1177/0969733014560930] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Ethics rounds are one way to support healthcare personnel in handling ethically difficult situations. A previous study in the present project showed that ethics rounds did not result in significant changes in perceptions of how ethical issues were handled, that is, in the ethical climate. However, there was anecdotal evidence that the ethics rounds were viewed as a positive experience and that they stimulated ethical reflection. AIM The aim of this study was to gain a deeper understanding of how the ethics rounds were experienced and why the intervention in the form of ethics rounds did not succeed in improving the ethical climate for the staff. RESEARCH DESIGN An exploratory and descriptive design with a qualitative approach was adopted, using individual interviews. PARTICIPANTS AND RESEARCH CONTEXT A total of 11 healthcare personnel, working in two different psychiatry outpatient clinics and with experience of participating in ethics rounds, were interviewed. ETHICAL CONSIDERATIONS The study was based on informed consent and was approved by one of the Swedish Regional Ethical Review Boards. FINDINGS The participants were generally positive about the ethics rounds. They had experienced changes by participating in the ethics rounds in the form of being able to see things from different perspectives as well as by gaining insight into ethical issues. However, these changes had not affected daily work. DISCUSSION A crucial question is whether or not increased reflection ability among the participants is a good enough outcome of ethics rounds and whether this result could have been measured in patient-related outcomes. Ethics rounds might foster cooperation among the staff and this, in turn, could influence patient care. CONCLUSION By listening to others during ethics rounds, a person can learn to see things from a new angle. Participation in ethics rounds can also lead to better insight concerning ethical issues.
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Hem MH, Pedersen R, Norvoll R, Molewijk B. Evaluating clinical ethics support in mental healthcare: a systematic literature review. Nurs Ethics 2014; 22:452-66. [PMID: 25091004 DOI: 10.1177/0969733014539783] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A systematic literature review on evaluation of clinical ethics support services in mental healthcare is presented and discussed. The focus was on (a) forms of clinical ethics support services, (b) evaluation of clinical ethics support services, (c) contexts and participants and (d) results. Five studies were included. The ethics support activities described were moral case deliberations and ethics rounds. Different qualitative and quantitative research methods were utilized. The results show that (a) participants felt that they gained an increased insight into moral issues through systematic reflection; (b) there was improved cooperation among multidisciplinary team members; (c) it was uncertain whether clinical ethics support services led to better patient care; (d) the issue of patient and client participation is complex; and (e) the implementation process is challenging. Clinical ethics support services have mainly been studied through the experiences of the participating facilitators and healthcare professionals. Hence, there is limited knowledge of whether and how various types of clinical ethics support services influence the quality of care and how patients and relatives may evaluate clinical ethics support services. Based on the six excluded 'grey zone articles', in which there was an implicit focus on ethics reflection, other ways of working with ethical reflection in practice are discussed. Implementing and evaluating clinical ethics support services as approaches to clinical ethics support that are more integrated into the development of good practice are in focus. In order to meet some of the shortcomings of the field of clinical ethics support services, a research project that aims to strengthen ethics support in the mental health services, including patients' and caregivers' views on ethical challenges, is presented.
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Svantesson M, Karlsson J, Boitte P, Schildman J, Dauwerse L, Widdershoven G, Pedersen R, Huisman M, Molewijk B. Outcomes of moral case deliberation--the development of an evaluation instrument for clinical ethics support (the Euro-MCD). BMC Med Ethics 2014; 15:30. [PMID: 24712735 PMCID: PMC4234013 DOI: 10.1186/1472-6939-15-30] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 03/21/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clinical ethics support, in particular Moral Case Deliberation, aims to support health care providers to manage ethically difficult situations. However, there is a lack of evaluation instruments regarding outcomes of clinical ethics support in general and regarding Moral Case Deliberation (MCD) in particular. There also is a lack of clarity and consensuses regarding which MCD outcomes are beneficial. In addition, MCD outcomes might be context-sensitive. Against this background, there is a need for a standardised but flexible outcome evaluation instrument. The aim of this study was to develop a multi-contextual evaluation instrument measuring health care providers' experiences and perceived importance of outcomes of Moral Case Deliberation. METHODS A multi-item instrument for assessing outcomes of Moral Case Deliberation (MCD) was constructed through an iterative process, founded on a literature review and modified through a multistep review by ethicists and health care providers. The instrument measures perceived importance of outcomes before and after MCD, as well as experienced outcomes during MCD and in daily work. A purposeful sample of 86 European participants contributed to a Delphi panel and content validity testing. The Delphi panel (n = 13), consisting of ethicists and ethics researchers, participated in three Delphi-rounds. Health care providers (n = 73) participated in the content validity testing through 'think-aloud' interviews and a method using Content Validity Index. RESULTS The development process resulted in the European Moral Case Deliberation Outcomes Instrument (Euro-MCD), which consists of two sections, one to be completed before a participant's first MCD and the other after completing multiple MCDs. The instrument contains a few open-ended questions and 26 specific items with a corresponding rating/response scale representing various MCD outcomes. The items were categorised into the following six domains: Enhanced emotional support, Enhanced collaboration, Improved moral reflexivity, Improved moral attitude, Improvement on organizational level and Concrete results. CONCLUSIONS A tentative instrument has been developed that seems to cover main outcomes of Moral Case Deliberation. The next step will be to test the Euro-MCD in a field study.
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Affiliation(s)
- Mia Svantesson
- Centre for Health Care Sciences, Örebro University hospital and School of Health and Medical Sciences, Örebro university, Örebro, Sweden.
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