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Samsami K, Chananeh M, Kamali F, Bagherzadeh R. Effect of moral case deliberation on midwives' knowledge and practice regarding respectful maternity care. Nurs Ethics 2024:9697330241248736. [PMID: 38753533 DOI: 10.1177/09697330241248736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
INTRODUCTION Although there have been reports of misbehavior and disrespectful maternal care by healthcare providers worldwide, there are few intervention studies aimed at promoting respectful care, particularly among midwives. RESEARCH OBJECTIVES The aim of this study was to examine the effect of Moral Case Deliberation (MCD) on the of midwives' knowledge and practice in the field of respectful maternity care. RESEARCH DESIGN AND METHODS This semi-experimental study involved 46 midwives working in the maternity departments of two hospitals affiliated with Bushehr University of Medical Sciences in 2023. The two hospitals were randomly divided into control and intervention groups. All midwives from both hospitals were included in the study. The Dilemma Method of MCD was implemented for midwives of intervention hospital. The Midwives' Knowledge and Practice of Respectful Maternity Care scale was used for data collection. It was administered both before and two weeks after the intervention. Data were analyzed using SPSS (version 20). ETHICAL CONSIDERATIONS The study was approved by ethics committee of Bushehr University of Medical Sciences in Bushehr, Iran (ethics code: IR.BPUMS.REC.1402.017). All participants provided written informed consent. FINDINGS The intervention group showed a significantly greater increase in knowledge scores from pre-test to post-test compared to the control group (p < .001). The intervention group had a significantly higher mean change score in practice self-assessment and practice peer evaluation, from pre-test to post-test, than in the control group (p < .001). DISCUSSION MCD based on the dilemma method can improve practice in the field of respect-oriented midwifery care by increasing knowledge and potentially changing attitudes. CONCLUSION The Dilemma Method of MCD improved midwives' knowledge and practice regarding respectful maternity care. This method can be included in the midwifery care quality improvement program to promote respectful maternity care. It is necessary to develop methods for wider dissemination of MCD in the cultural context of Iran.
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Ligtenberg W, Stolper M, Molewijk B. Ethics support for ethics support: the development of the Confidentiality Compass for dealing with moral challenges concerning (breaching) confidentiality in moral case deliberation. BMC Med Ethics 2024; 25:49. [PMID: 38702729 PMCID: PMC11067180 DOI: 10.1186/s12910-024-01039-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 03/18/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Confidentiality is one of the central preconditions for clinical ethics support (CES). CES cases which generate moral questions for CES staff concerning (breaching) confidentiality of what has been discussed during CES can cause moral challenges. Currently, there seems to be no clear policy or guidance regarding how CES staff can or should deal with these moral challenges related to (not) breaching confidentiality within CES. Moral case deliberation is a specific kind of CES. METHOD Based on experiences and research into MCD facilitators' needs for ethics support in this regard, we jointly developed an ethics support tool for MCD facilitators: the Confidentiality Compass. This paper describes the iterative developmental process, including our theoretical viewpoints and reflections on characteristics of CES tools in general. RESULTS The content and goals of the ethics support tool, which contains four elements, is described. Part A is about providing information on the concept of confidentiality in MCD, part B is a moral compass with reflective questions, part C focuses on courses of action for careful handling of moral challenges related to confidentiality. Part D contains general lessons, best practices and tips for dealing with confidentiality in future cases. CONCLUSIONS This paper concludes with providing some lessons-learned related to developing ethics support tools and some reflections on issues of quality and normativity of ethics support tools.
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Affiliation(s)
- Wieke Ligtenberg
- Department Ethics, Law & Humanities, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Margreet Stolper
- Department Ethics, Law & Humanities, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bert Molewijk
- Clinical Ethics Support, Center for Medical Ethics, Oslo, Norway
- Department Ethics, Law & Humanities, Amsterdam UMC, Ethics Support & Research Integrity, Amsterdam, The Netherlands
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Jakobsen LM, Molewijk B, de Snoo-Trimp J, Svantesson M, Ursin G. What is a High-Quality Moral Case Deliberation?-Facilitators' Perspectives in the Euro-MCD Project. HEC Forum 2024:10.1007/s10730-023-09519-w. [PMID: 38315250 DOI: 10.1007/s10730-023-09519-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2023] [Indexed: 02/07/2024]
Abstract
The evaluation of the European Moral Case Deliberation Outcomes project (Euro-MCD) has resulted in a revised evaluation instrument, knowledge about the content of MCD (moral case deliberation), and the perspectives of those involved. In this paper, we report on a perspective that has been overlooked, the facilitators'. We aim to describe facilitators' perceptions of high-quality moral case deliberation and their Euro-MCD sessions. The research took place in Norway, Sweden, and the Netherlands using a survey combined with interviews with 41 facilitators. Facilitators' perceived that attaining a high-quality MCD implies fostering a safe and respectful atmosphere, creating a wondering mode, being an attentive authority, developing moral reflective skills, reaching a common understanding, and ensuring organisational prerequisites for the MCD sessions. Our central conclusion is that efforts at three levels are required to attain a high-quality MCD: trained and virtuous facilitator; committed, respectful participants; and organizational space. Furthermore, managers have a responsibility to prepare MCD participants for what it means to take part in MCD.
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Affiliation(s)
- Lena M Jakobsen
- Department of Health and Care Sciences, Faculty of Health Sciences, UiT The Arctic University of Norway, Harstad, Norway.
- Faculty of Nursing and Health Science, Nord University, Bodø, Norway.
| | - Bert 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
| | - Janine de Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam UMC, VU University, Amsterdam, The Netherlands
| | - Mia Svantesson
- Faculty of Medicine and Health, University Health Care Research Centre, Örebro University, Örebro, Sweden
| | - Gøril Ursin
- Faculty of Nursing and Health Science, Nord University, Bodø, Norway
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Frank C, Rantala A, Svensson A, Sterner A, Green J, Bremer A, Holmberg B. Ethics rounds in the ambulance service: a qualitative evaluation. BMC Med Ethics 2024; 25:8. [PMID: 38238736 PMCID: PMC10795226 DOI: 10.1186/s12910-024-01002-6] [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] [Received: 11/20/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND It is a common ethical challenge for ambulance clinicians to care for patients with impaired decision-making capacities while assessing and determining the degree of decision-making ability and considering ethical values. Ambulance clinicians' ethical competence seems to be increasingly important in coping with such varied ethical dilemmas. Ethics rounds is a model designed to promote the development of ethical competence among clinicians. While standard in other contexts, to the best of our knowledge, it has not been applied within the ambulance service context. Thus, the aim of this study was to describe ambulance clinicians' experiences of participating in ethics rounds. METHODS This was a qualitative descriptive study, evaluating an intervention. Data were collected through sixteen interviews with ambulance clinicians who had participated in an intervention involving ethics rounds. The analysis was performed by use of content analysis. RESULTS Two themes describe the participants' experiences: (1) Reflecting freely within a given framework, and (2) Being surprised by new insights. The following categories form the basis of the themes; 1a) Gentle guidance by the facilitator, 1b) A comprehensible structure, 2a) New awareness in the face of ethical problems, and 2b) Shared learning through dialogue. CONCLUSION Incorporating structured ethics rounds seems to create a continuous development in ethical competence that may improve the quality of care in the ambulance service. Structured guidance and facilitated group reflections offer ambulance clinicians opportunities for both personal and professional development. An important prerequisite for the development of ethical competence is a well-educated facilitator. Consequently, this type of ethics rounds may be considered a useful pedagogical model for the development of ethical competence in the ambulance service.
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Affiliation(s)
- Catharina Frank
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden.
- Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden.
- Department of Health Sciences, Red Cross University College, Stockholm, Sweden.
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Växjö, SE-352 52, Sweden.
| | - Andreas Rantala
- Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Department of Ambulance Service, Region Skåne, Helsingborg, Sweden
| | - Anders Svensson
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden
- Department of Ambulance Service, Region Kronoberg, Sweden
| | - Anders Sterner
- Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden
- Faculty of Caring Sciences, Work Life and Social Welfare, University of Borås, Borås, Sweden
| | - Jessica Green
- Department of Ambulance Services, Region Kalmar County, Kalmar, Sweden
| | - Anders Bremer
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden
| | - Bodil Holmberg
- Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- Centre of Interprofessional Collaboration within Emergency care (CICE), Linnaeus University, Växjö, Sweden
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van Schaik M, Pasman HRR, Widdershoven GA, De Snoo-Trimp J, Metselaar S. Effectiveness of CURA: Healthcare professionals' moral resilience and moral competences. Nurs Ethics 2023:9697330231218344. [PMID: 38031920 DOI: 10.1177/09697330231218344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Background: Clinical ethics support instruments aim to support healthcare professionals in dealing with moral challenges in clinical practice. CURA is a relatively new instrument tailored to the wishes and needs of healthcare professionals in palliative care, especially nurses. It aims to foster their moral resilience and moral competences.Aim: To investigate the effects of using CURA on healthcare professionals regarding their Moral Resilience and Moral Competences.Design: Single group pre-/post-test design with two questionnaires.Methods: Questionnaires used were the Rushton Moral Resilience Scale measuring Moral Resilience and the Euro-MCD, measuring Moral Competences. Respondents mainly consisted of nurses and nurse assistants who used CURA in daily practice. Forty-seven respondents contributed to both pre- and post-test with 18 months between both tests. Analysis was done using descriptive statistics and Wilcoxon signed rank tests. This study followed the SQUIRE checklist.Ethical considerations: This study was approved by the Institutional Review Board of Amsterdam UMC. Informed consent was obtained from all respondents.Results: The total Moral Resilience score and the scores of two subscales of the RMRS, that is, Responses to Moral Adversity and Relational Integrity, increased significantly. All subscales of the Euro-MCD increased significantly at posttest. Using CURA more often did not lead to significant higher scores on most (sub) scales.Conclusion: This study indicates that CURA can be used to foster moral resilience and moral competences of healthcare professionals. CURA therefore is a promising instrument to support healthcare professionals in dealing with moral challenges in everyday practice.
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Affiliation(s)
- Malene van Schaik
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - H Roeline Rw Pasman
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Guy Am Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Janine De Snoo-Trimp
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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van Schaik M, Kröger C, Zuidema L, Stolper M, Widdershoven G, Pasman HR, Metselaar S. Training nurses to facilitate and implement CURA in palliative care institutions: development and evaluation of a blended learning program. BMC Palliat Care 2023; 22:158. [PMID: 37865740 PMCID: PMC10590004 DOI: 10.1186/s12904-023-01284-4] [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] [Received: 05/22/2023] [Accepted: 10/13/2023] [Indexed: 10/23/2023] Open
Abstract
BACKGROUND Healthcare professionals in palliative care are found to be confronted with moral challenges on a frequent basis. CURA is a low-threshold instrument for dialogical ethical reflection that was developed to deal with these challenges. A previous study identified the need of healthcare professionals to be trained to introduce CURA in their organization, initiate and facilitate reflections with CURA, and contribute to the implementation of CURA. The aim of this study was to develop and evaluate a training for professionals to become 'CURA-ambassadors'. METHODS The training was developed in a participatory way in two cycles. We trained 72 healthcare professionals. The training was evaluated by means of a questionnaire and six semi-structured interviews. RESULTS The study resulted in a blended learning training combining training sessions with an e-module and with practicing with organizing and facilitating CURA in daily healthcare practice. The main objectives of the training are to enable CURA-ambassadors to introduce CURA within their organization, initiate and facilitate ethical reflections using CURA, and contribute to the implementation of CURA. Participants were generally positive about the training program and the trainers. Technical difficulties related to the e-module were mentioned as main point of improvement. DISCUSSION The training program can generate ownership, responsibility, and competency among CURA-ambassadors, which are essential foundations for implementing complex interventions in healthcare practice. The training program received positive evaluations shortly after completing the program. This study adds to our understanding of what is needed for healthcare professionals to use CURA, in order to support them in dealing with moral challenges and to foster their moral resilience. Further research is needed to assess whether participants experience the training as sufficient and effective when using and implementing CURA structurally in their organizations over a longer period of time.
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Affiliation(s)
- Malene van Schaik
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
| | - Charlotte Kröger
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Lisa Zuidema
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Margreet Stolper
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Guy Widdershoven
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - H Roeline Pasman
- Department of Public and Occupational Health, Expertise Center for Palliative Care, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands
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Kröger C, Molewijk AC, Metselaar S. Developing Organizational Diversity Statements Through Dialogical Clinical Ethics Support: The Role of the Clinical Ethicist. JOURNAL OF BIOETHICAL INQUIRY 2023; 20:379-395. [PMID: 37233964 PMCID: PMC10624755 DOI: 10.1007/s11673-023-10258-3] [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: 07/26/2021] [Accepted: 11/20/2022] [Indexed: 05/27/2023]
Abstract
In pluralist societies, stakeholders in healthcare may have different experiences of and moral perspectives on health, well-being, and good care. Increasing cultural, religious, sexual, and gender diversity among both patients and healthcare professionals requires healthcare organizations to address these differences. Addressing diversity, however, comes with inherent moral challenges; for example, regarding how to deal with healthcare disparities between minoritized and majoritized patients or how to accommodate different healthcare needs and values. Diversity statements are an important strategy for healthcare organizations to define their normative ideas with respect to diversity and to establish a point of departure for concrete diversity approaches. We argue that healthcare organizations ought to develop diversity statements in a participatory and inclusive way in order to promote social justice. Furthermore, we maintain that clinical ethicists can support healthcare organizations in developing diversity statements in a more participatory way by fostering reflective dialogues through clinical ethics support. We will use a case example from our own practice to explore what such a developmental process may look like. We will critically reflect on the procedural strengths and challenges as well as on the role of the clinical ethicist in this example.
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Affiliation(s)
- Charlotte Kröger
- Department of Ethics, Law and Humanities, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1089a, 1081 HV, Amsterdam, Netherlands.
- Faculty of Military Sciences, Netherlands Defence Academy, Breda, The Netherlands.
| | - Albert C Molewijk
- Department of Ethics, Law and Humanities, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1089a, 1081 HV, Amsterdam, Netherlands
- Centre for Medical Ethics, University of Oslo, Oslo, Norway
| | - Suzanne Metselaar
- Department of Ethics, Law and Humanities, Amsterdam Public Health research institute, Amsterdam UMC, Vrije Universiteit Amsterdam, De Boelelaan 1089a, 1081 HV, Amsterdam, Netherlands
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van den Bosch G, van Schaik M, Pasman HR, Janssens R, Widdershoven G, Metselaar S. Moral Challenges of Nurses and Volunteers in Dutch Palliative Care. A Qualitative Study. J Palliat Care 2023; 38:364-371. [PMID: 35612868 PMCID: PMC10350729 DOI: 10.1177/08258597221098129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To identify moral challenges experienced by nurses and volunteers in palliative care. Methods: A qualitative hermeneutic research design was used. Interviews with nurses (N = 10) and volunteers (N = 4) working in palliative care, in-home care, and hospice setting. Participants were recruited through maximum variation, a purposive sampling technique. Transcriptions were analyzed using qualitative thematic content analysis and open coding. Results: Two themes were identified, each with three subthemes: theme (A) Moral challenges regarding organizational and professional aspects contained the subthemes (1) dealing with protocols and regulations, (2) different professional perspectives on good care, and (3) limits of professionalism. Theme (B) Moral challenges regarding the patient and their family members contained the subthemes (1) dealing with the patient's wishes, (2) the patient's wish to die, and (3) dealing with family members. Conclusion: Nurses and volunteers working in palliative care are confronted with a wide range of moral challenges. Insight into 'real-world ethical challenges' of healthcare providers is important to provide adequate support to nurses and volunteers working in palliative care.
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Affiliation(s)
| | | | | | - Rien Janssens
- Ethics, Law and Humanities, Amsterdam, the Netherlands
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Oladele DA, Odusola AO, Odubela O, Nwaozuru U, Calvin C, Musa Z, Idigbe I, Nwakwo C, Odejobi Y, Aifah A, Kanneh N, Mishra S, Onakomaiya D, Iwelunmor J, Ogedegbe O, Ezechi O. Training primary healthcare workers on a task-strengthening strategy for integrating hypertension management into HIV care in Nigeria: implementation strategies, knowledge uptake, and lessons learned. BMC Health Serv Res 2023; 23:673. [PMID: 37344869 PMCID: PMC10286327 DOI: 10.1186/s12913-023-09603-4] [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] [Received: 02/20/2023] [Accepted: 05/24/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND With improved access to anti-retroviral drugs, persons living with HIV/AIDS (PLWHA) are living longer but with attendant increased risks of non-communicable diseases (NCDs). The increasing burden of NCDs, especially hypertension, could reverse gains attributed to HIV care. Nurses and Community Health Officers (CHO) in Nigeria are cardinal in delivering primary health care. A task-strengthening strategy could enable them to manage hypertension in HIV care settings. This study aimed to assess their knowledge and practice of hypertension management among Healthcare workers (HCWs) and to explore the challenges involved in conducting onsite training during pandemics. METHODS Nurses and CHOs in the employment of the Lagos State Primary Health Care Board (LSPHCB), Lagos State, Nigeria, were recruited. They were trained through hybrid (virtual and onsite) modules before study implementation and a series of refresher trainings. A pre-and post-training test survey was administered, followed by qualitative interviews to assess skills and knowledge uptake, the potential barriers and facilitators of task-sharing in hypertension management in HIV clinics, and the lessons learned. RESULTS Sixty HCWs participated in the two-day training at baseline. There was a significant improvement in the trainees' knowledge of hypertension management and control. The average score during the pre-test and post-test was 59% and 67.6%, respectively. While about 75% of the participants had a good knowledge of hypertension, its cause, symptoms, and management, 20% had moderate knowledge, and 5% had poor knowledge at baseline. There was also an increase in the mean score between the pre-test and post-test of the refresher training using paired t-tests (P < 0.05). Role-playing and multimedia video use improved the participants' uptake of the training. The primary barrier and facilitator of task sharing strategy in hypertension management reported were poor delineation of duties among HCWs and the existing task shifting at the Primary Healthcare Centres (PHC) level, respectively. CONCLUSIONS The task strengthening strategy is relevant in managing hypertension in HIV clinics in Nigeria. The capacity development training for the nurses and CHOs involved in the Integration of Hypertension Management into HIV Care in Nigeria: A Task Strengthening Strategy (TASSH-Nigeria) study yielded the requisite improvement in knowledge uptake, which is a reassurance of the delivery of the project outcomes at the PHCs.
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Affiliation(s)
- David Ayoola Oladele
- Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria.
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO 63103, USA.
| | | | | | | | - Colvin Calvin
- New York University School of Medicine, New York City, NY 10016, USA
| | - Zaidat Musa
- Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria
| | - Ifeoma Idigbe
- Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria
| | - Chioma Nwakwo
- Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria
| | - Yemi Odejobi
- Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria
| | - Angela Aifah
- New York University School of Medicine, New York City, NY 10016, USA
| | - Nafesa Kanneh
- New York University School of Medicine, New York City, NY 10016, USA
| | - Shivani Mishra
- New York University School of Medicine, New York City, NY 10016, USA
| | | | - Juliet Iwelunmor
- Department of Behavioral Science and Health Education, College for Public Health and Social Justice, Saint Louis University, Saint Louis, MO 63103, USA
| | | | - Oliver Ezechi
- Nigerian Institute of Medical Research, Yaba, Lagos, Nigeria
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Hosseini ZS, Tavafian SS, Ahmadi O, Maghbouli R. Effectiveness of a theory-based educational intervention on work-related musculoskeletal disorders preventive behaviors among assembly-line female workers: a study protocol for a randomized controlled trial. Trials 2023; 24:377. [PMID: 37277774 DOI: 10.1186/s13063-023-07391-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 05/18/2023] [Indexed: 06/07/2023] Open
Abstract
BACKGROUND The use of preventive behaviors of musculoskeletal disorders (MSDs) requires proper training, which leads to correct decisions regarding maintaining postures at work and performing stretching exercises. Due to very repetitive work, applying manual force, improper postures, and static contractions of proximal muscles, assembly-line female workers suffer from musculoskeletal pains. It is assumed that structured and theory-based educational intervention using a learning-by-doing (LBD) approach may increase the preventive behaviors against MSDs and reduce the consequences of these disorders. METHODS This randomized controlled trial (RCT) will be conducted in three phases: phase 1: validation of the compiled questionnaire, phase 2: determining the social cognitive theory (SCT) constructs that predict the preventive behaviors of MSDs in assembly-line female workers, and phase 3: designing and implementing the educational theory. The educational intervention is based on the LBD approach, and the study population includes assembly-line female workers in electronic industries of Iran, who are randomly divided into two intervention and control groups. The intervention group received the educational intervention in the workplace and the control group does not receive any intervention. The theory-based educational intervention includes evidence-based information along with pictures, fact sheets, and published literature about a good posture at work and the need to perform proper stretching exercises. The educational intervention aims to improve the knowledge, skills, self-efficacy, and intention of assembly-line female workers to adopt preventive behaviors of MSDs. DISCUSSION The present study will evaluate the effects of maintaining a good posture at work and performing stretching exercises on the adherence to preventive behaviors of MSDs among assembly-line female workers. The developed intervention is easily implemented and evaluated in a short period of time based on the improved score of the rapid upper limb assessment (RULA) method and the mean score of adherence to stretching exercises and can be provided by a health, safety, and environment (HSE) expert. TRIAL REGISTRATION ClinicalTrials.gov IRCT20220825055792N1. Registered on 23 September 2022 with the IRCTID.
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Affiliation(s)
- Zakieh Sadat Hosseini
- Department of Health Education, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Sedigheh Sadat Tavafian
- Department of Health Education, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran.
| | - Omran Ahmadi
- Department of Occupational Health, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Reza Maghbouli
- Hasheminejad Hospital, School of Medicine, Iran University of Medical Sciences, Tehran, Iran.
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Ashida K, Kawashima T, Molewijk AC, de Snoo-Trimp JC, Kawakami A, Tanaka M. Moral distress reduction using moral case deliberation in Japan: A mixed-methods study. Jpn J Nurs Sci 2023:e12528. [PMID: 36758945 DOI: 10.1111/jjns.12528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 01/11/2023] [Accepted: 01/17/2023] [Indexed: 02/11/2023]
Abstract
AIMS This study aims to develop and examine the effectiveness of a support program for reducing moral distress of nurses, based on the moral case deliberation methodology, and to study the feasibility of its implementation. METHODS Study design was an intervention study with pre/post-comparison. The support program included a short lecture and three moral case deliberation sessions for nurses working in an acute care hospital. The Measure of Moral Distress for Healthcare Professionals (MMD-HP) and the Euro-MCD (Moral Case Deliberation) 2.0 scale were used for pre/post-comparison, using the Wilcoxon's signed-rank test. Furthermore, post-intervention interviews were conducted with consenting participants to determine the reasons for changes in pre/post-intervention quantitative data. Of the 34 participants, 29 completed the post-questionnaire and were included in the quantitative data analysis, and 27 were included in the qualitative data analysis. RESULTS The mean MMD-HP total scores increased from 147.5 ± 61.0 to 159.3 ± 66.7, but not significantly (p = .375). The mean score of moral competence, a sub-scale of the Euro-MCD 2.0, increased significantly from 15.4 ± 2.4 to 16.4 ± 2.8 after the intervention (p = .036). A qualitative analysis revealed increased moral sensitivity to ethically difficult situations and improved analytical skills as the reasons for change in scores pre/post-intervention. CONCLUSION The results of the qualitative analysis suggested the effectiveness of the intervention. The moral distress score increased, although not significantly, and moral competence also increased, suggesting the participants' values changed after the intervention. It was found that the support program using MCD is expected to improve participants' moral competence.
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Affiliation(s)
- Kaoru Ashida
- Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Kanto Gakuin University, Yokohama, Japan
| | - Tetsuharu Kawashima
- Tokyo Medical and Dental University (TMDU), Tokyo, Japan.,Kanto Gakuin University, Yokohama, Japan
| | - Albert C Molewijk
- Department of Medical Humanities, Amsterdam UMC, Amsterdam, The Netherlands
| | | | - Aki Kawakami
- Tokyo Medical and Dental University (TMDU), Tokyo, Japan
| | - Makoto Tanaka
- Tokyo Medical and Dental University (TMDU), Tokyo, Japan
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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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Weiner C, Pergert P, Castor A, Molewijk B, Bartholdson C. Difficult situations and moral questions raised during moral case deliberations in Swedish childhood cancer care – A qualitative nationwide overview. Eur J Oncol Nurs 2022; 60:102189. [DOI: 10.1016/j.ejon.2022.102189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/18/2022] [Accepted: 08/04/2022] [Indexed: 11/27/2022]
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Molewijk B, de Snoo-Trimp J, Stolper M, Widdershoven G. Improving Ethics Support: Seeing and Organizing Ethics Support Differently. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2022; 22:53-55. [PMID: 35420525 DOI: 10.1080/15265161.2022.2044565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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15
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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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Knox JBL. The Ethics Laboratory: A Dialogical Practice for Interdisciplinary Moral Deliberation. HEC Forum 2021; 35:185-199. [PMID: 34559330 DOI: 10.1007/s10730-021-09460-w] [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] [Accepted: 09/10/2021] [Indexed: 11/29/2022]
Abstract
Recent advancements in therapeutic and diagnostic medicine, along with the creation of large biobanks and methods for monitoring health technologies, have improved the prospects for preventing, treating, and curing illness. These same advancements, however, give rise to a plethora of ethical questions concerning good decision-making and best action. These ethical questions engage policymakers, practitioners, scientists, and researchers from a variety of fields in different ways. Collaborations between professionals in the medical and health sciences and the social sciences and humanities often take an asymmetrical form, as when social scientists use ethnographic approaches to study the moral issues and practices of physicians. The ethics laboratory described in this article is a cross-sectoral and inter-disciplinary forum for collaborative investigation on important moral topics. It offers an experimental way of unpacking implied assumptions, underlying values, and comparable notions from different professional healthcare fields. The aim of this article is to present the ethics laboratory's methodology. The article offers a model and a hermeneutical framework that rests on a dialogical approach to ethical questions. The model and the framework derive from a Danish research project, Personalized Medicine in the Welfare State. This article uses personalized medicine as a point of reference, though it offers an argument for the applicability of the model more broadly.
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Evans N, Marusic A, Foeger N, Lofstrom E, van Hoof M, Vrijhoef-Welten S, Inguaggiato G, Dierickx K, Bouter L, Widdershoven G. Virtue-based ethics and integrity of research: train-the-trainer programme for upholding the principles and practices of the European Code of Conduct for Research Integrity (VIRT2UE). RESEARCH IDEAS AND OUTCOMES 2021. [DOI: 10.3897/rio.7.e68258] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Recognising the importance of addressing ethics and research integrity (ERI) in Europe, in 2017, the All European Academies (ALLEA) published a revised and updated European Code of Conduct for Research Integrity (ECoC). Consistent application of the ECoC by researchers across Europe will require its widespread dissemination, as well as an innovative training programme and novel tools to enable researchers to truly uphold and internalise the principles and practices listed in the Code.
Aim: VIRT2UE aims to develop a sustainable train-the-trainer blended learning programme enabling contextualised ERI teaching across Europe focusing on understanding and upholding the principles and practices of the ECoC.
Vision: The VIRT2UE project recognises that researchers not only need to have knowledge of the ECoC, but also to be able to truly uphold and internalise the principles underpinning the code. They need to learn how to integrate them into their everyday practice and understand how to act in concrete situations. VIRT2UE addresses this challenge by providing ERI trainers and researchers with an innovative blended (i.e. combined online and off-line approaches) learning programme that draws on a toolbox of educational resources and incorporates an e-learning course (including a YouTube channel) and face-to-face sessions designed to foster moral virtues. ERI trainers and researchers from academia and industry will have open access to online teaching material. Moreover, ERI trainers will learn how to facilitate face-to-face sessions of researchers, which focus on learning how to apply the content of the teaching material to concrete situations in daily practice.
Objectives: VIRT2UE’s work packages (WP) will: conduct a conceptual mapping amongst stakeholders to identify and rank the virtues which are essential for good scientific practice and their relationship to the principles and practices of the ECoC (WP1); identify and consult ERI trainers and the wider scientific community to understand existing capacity and deficiencies in ERI educational resources (WP2); develop the face-to-face component of the train-the-trainer programme which provides trainers with tools to foster researchers’ virtues and promote the ECoC and iteratively develop the programme based on evaluations (WP3); produce educational materials for online learning by researchers and trainers (WP4); implement and disseminate the train-the-trainer programme across Europe, ensuring the training of sufficient trainers for each country and build capacity and consistency by focusing on underdeveloped regions and unifying fragmented efforts (WP5); and develop the online training platform and user interface, which will be instrumental in evaluation of trainers’ and researchers’ needs and project sustainability (WP6).
Impact: The VIRT2UE training programme will promote consistent application of the ECoC across Europe. The programme will affect behaviour on the individual level of trainers and researchers – simultaneously developing an understanding of the ECoC and other ERI issues, whilst also developing scientific virtues, enabling the application of the acquired knowledge to concrete situations and complex moral dilemmas. Through a dedicated embedding strategy, the programme will also have an impact on an institutional level. The train-the-trainer approach multiplies the impact of the programme by reaching current and future European ERI trainers and, subsequently, the researchers they train.
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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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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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20
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Svantesson M, Griffiths F, White C, Bassford C, Slowther A. Ethical conflicts during the process of deciding about ICU admission: an empirically driven ethical analysis. JOURNAL OF MEDICAL ETHICS 2021; 47:medethics-2020-106672. [PMID: 33402429 PMCID: PMC8639921 DOI: 10.1136/medethics-2020-106672] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 10/20/2020] [Accepted: 10/25/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Besides balancing burdens and benefits of intensive care, ethical conflicts in the process of decision-making should also be recognised. This calls for an ethical analysis relevant to clinicians. The aim was to analyse ethically difficult situations in the process of deciding whether a patient is admitted to intensive care unit (ICU). METHODS Analysis using the 'Dilemma method' and 'wide reflective equilibrium', on ethnographic data of 45 patient cases and 96 stakeholder interviews in six UK hospitals. ETHICAL ANALYSIS Four moral questions and associated value conflicts were identified. (1) Who should have the right to decide whether a patient needs to be reviewed? Conflicting perspectives on safety/security. (2) Does the benefit to the patient of getting the decision right justify the cost to the patient of a delay in making the decision? Preventing longer-term suffering and understanding patient's values conflicted with preventing short-term suffering and provision of security. (3) To what extent should the intensivist gain others' input? Professional independence versus a holistic approach to decision-making. (4) Should the intensivist have an ongoing duty of care to patients not admitted to ICU? Short-term versus longer-term duty to protect patient safety. Safety and security (experienced in a holistic sense of physical and emotional security for patients) were key values at stake in the ethical conflicts identified. The life-threatening nature of the situation meant that the principle of autonomy was overshadowed by the duty to protect patients from harm. The need to fairly balance obligations to the referred patient and to other patients was also recognised. CONCLUSION Proactive decision-making including advance care planning and escalation of treatment decisions may support the inclusion of patient autonomy. However, our analysis invites binary choices, which may not sufficiently reflect reality. This calls for a complementary relational ethics analysis.
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Affiliation(s)
- Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Frances Griffiths
- Warwick Medical School, University of Warwick Warwick Medical School, Coventry, UK
| | - Catherine White
- Patient and Public Representative, Trustee, ICUsteps - the Intensive Care Patient Support Charity, Coventry, UK
| | - Chris Bassford
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, Coventry, UK
| | - AnneMarie Slowther
- Warwick Medical School, University of Warwick Warwick Medical School, Coventry, UK
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Charre D, Cano N, Malzac P, Habbachi M, Fond G, Boyer L. Mise en place et évaluation de séances d’éthique appliquée dans un service de psychiatrie générale en France. ANNALES MEDICO-PSYCHOLOGIQUES 2020. [DOI: 10.1016/j.amp.2019.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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22
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Vrouenraets LJJJ, Hartman LA, Hein IM, de Vries ALC, de Vries MC, Molewijk BAC. Dealing with Moral Challenges in Treatment of Transgender Children and Adolescents: Evaluating the Role of Moral Case Deliberation. ARCHIVES OF SEXUAL BEHAVIOR 2020; 49:2619-2634. [PMID: 32592076 PMCID: PMC7497454 DOI: 10.1007/s10508-020-01762-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 06/03/2020] [Accepted: 06/05/2020] [Indexed: 05/10/2023]
Abstract
Treatment teams providing affirmative medical transgender care to young people frequently face moral challenges arising from the care they provide. An adolescent's capacity to consent, for example, could raise several issues and challenges. To deal with these challenges more effectively, several Dutch treatment teams started using a relatively well-established form of clinical ethics support (CES) called Moral Case Deliberation (MCD). MCD is a facilitator-led, collective moral inquiry based on a real case. This study's purpose is to describe the teams' perceived value and effectiveness of MCD. We conducted a mixed methods evaluation study using MCD session reports, individual interviews, focus groups, and MCD evaluation questionnaires. Our results show that Dutch transgender care providers rated MCD as highly valuable in situations where participants were confronted with moral challenges. The health care providers reported that MCD increased mutual understanding and open communication among team members and strengthened their ability to make decisions and take action when managing ethically difficult circumstances. However, the health care providers also expressed criticisms of MCD: some felt that the amount of time spent discussing individual cases was excessive, that MCD should lead to more practical and concrete results, and that MCD needed better integration and follow-up in the regular work process. We recommend future research on three matters: studying how MCD contributes to the quality of care, involvement of transgender people themselves in MCD, and integration of CES into daily work processes.
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Affiliation(s)
| | - Laura A Hartman
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Irma M Hein
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, location Academic Medical Center, Amsterdam, The Netherlands
| | - Annelou L C de Vries
- Department of Child and Adolescent Psychiatry, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
| | - Martine C de Vries
- Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Bert A C Molewijk
- Department of Medical Humanities, Amsterdam Public Health Research Institute, Amsterdam University Medical Centers, location VU University Medical Center, Amsterdam, The Netherlands
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Grosek Š, Kučan R, Grošelj J, Oražem M, Grošelj U, Erčulj V, Lajovic J, Borovečki A, Ivanc B. The first nationwide study on facing and solving ethical dilemmas among healthcare professionals in Slovenia. PLoS One 2020; 15:e0235509. [PMID: 32663206 PMCID: PMC7360038 DOI: 10.1371/journal.pone.0235509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 06/16/2020] [Indexed: 11/19/2022] Open
Abstract
Background Healthcare professionals (HCPs), patients and families are often faced with ethical dilemmas. The role of healthcare ethics committees (HECs) is to offer support in these situations. Aim The primary objective was to study how often HCPs encounter ethical dilemmas. The secondary objective was to identify the main types of ethical dilemmas encountered and how HCPs solve them. Subjects and methods We conducted a cross-sectional, survey-based study among HCPs in 14 Slovenian hospitals. A questionnaire was designed and validated by HCPs who were selected by proportional stratified sampling. Data collection took place between April 2015 and April 2016. Results The final sample size was n = 485 (385 or 79.4%, female). The response rates for HCPs working in secondary and tertiary level institutions were 45% and 51%, respectively. Three hundred and forty (70.4%) of 485 HCPs (very) frequently encountered ethical dilemmas. Frequent ethical dilemmas were waiting periods for diagnostics or treatment, suboptimal working conditions due to poor interpersonal relations on the ward, preserving patients’ dignity, and relations between HCPs and patients. Physicians and nurses working in secondary level institutions, compared to their colleagues working in tertiary level institutions, more frequently encountered ethical dilemmas with respect to preserving patients’ dignity, protecting patients’ information, and relations between HCPs and patients. In terms of solutions, all HCPs most frequently discussed ethical dilemmas with co-workers (colleagues), and with the head of the department. According to HCPs, the most important role of HECs is staff education, followed by improving communication, and reviewing difficult ethical cases. Conclusions Waiting periods for diagnostics and treatment and suboptimal working conditions due to poor interpersonal relations are considered to be among the most important ethical issues by HCPs in Slovenian hospitals. The most important role of HECs is staff education, improving communication, and reviewing difficult ethical cases.
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Affiliation(s)
- Štefan Grosek
- Division of Surgery, Department of Paediatric Surgery and Intensive Therapy, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Chair of Paediatrics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Neonatology Section, Division of Obstetrics and Gynaecology, Department of Perinatology, University Medical Centre, Ljubljana, Slovenia
| | - Rok Kučan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Jon Grošelj
- Theological Faculty, University of Ljubljana, Ljubljana, Slovenia
| | - Miha Oražem
- Department of Radiation Oncology, Ljubljana Institute of Oncology, Ljubljana, Slovenia
| | - Urh Grošelj
- Department of Paediatric Endocrinology, Diabetes and Metabolic Diseases, University Children's Hospital, UMC Ljubljana, Ljubljana, Slovenia
| | - Vanja Erčulj
- Rho Sigma Research & Statistics, Ljubljana, Slovenia
- Faculty of Criminal Justice and Security, University of Maribor, Slovenia
| | - Jaro Lajovic
- Rho Sigma Research & Statistics, Ljubljana, Slovenia
| | - Ana Borovečki
- Andrija Štampar School of Public Health, School of Medicine, University of Zagreb, Zagreb, Croatia
| | - Blaž Ivanc
- Faculty of Health Sciences, University of Ljubljana, Ljubljana, Slovenia
- * E-mail:
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Stolper M, Pedersen R, Molewijk B. Examining the Doing of Ethics Support Staff. A Dialogical Approach Toward Assessing the Quality of Facilitators of Moral Case Deliberation. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2020; 20:42-44. [PMID: 32116179 DOI: 10.1080/15265161.2020.1714805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
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25
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Teti SL. A Listening Tour: Pediatric Clinical Ethics Rounds. THE JOURNAL OF CLINICAL ETHICS 2020. [DOI: 10.1086/jce2020311027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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26
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Van Baarle EM, Potma MC, van Hoek MEC, Hartman LA, Molewijk BAC, van Gurp JLP. Lessons learned from implementing a responsive quality assessment of clinical ethics support. BMC Med Ethics 2019; 20:78. [PMID: 31675970 PMCID: PMC6824048 DOI: 10.1186/s12910-019-0418-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 10/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Various forms of Clinical Ethics Support (CES) have been developed in health care organizations. Over the past years, increasing attention has been paid to the question of how to foster the quality of ethics support. In the Netherlands, a CES quality assessment project based on a responsive evaluation design has been implemented. CES practitioners themselves reflected upon the quality of ethics support within each other's health care organizations. This study presents a qualitative evaluation of this Responsive Quality Assessment (RQA) project. METHODS CES practitioners' experiences with and perspectives on the RQA project were collected by means of ten semi-structured interviews. Both the data collection and the qualitative data analysis followed a stepwise approach, including continuous peer review and careful documentation of the decisions. RESULTS The main findings illustrate the relevance of the RQA with regard to fostering the quality of CES by connecting to context specific issues, such as gaining support from upper management and to solidify CES services within health care organizations. Based on their participation in the RQA, CES practitioners perceived a number of changes regarding CES in Dutch health care organizations after the RQA: acknowledgement of the relevance of CES for the quality of care; CES practices being more formalized; inspiration for developing new CES-related activities and more self-reflection on existing CES practices. CONCLUSIONS The evaluation of the RQA shows that this method facilitates an open learning process by actively involving CES practitioners and their concrete practices. Lessons learned include that "servant leadership" and more intensive guidance of RQA participants may help to further enhance both the critical dimension and the learning process within RQA.
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Affiliation(s)
- Eva M Van Baarle
- Netherlands Defense Academy, Breda, the Netherlands. .,Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands.
| | - Marieke C Potma
- Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands.,Department of Care Ethics, University of Humanistic Studies (UvH), Utrecht, the Netherlands
| | - Maria E C van Hoek
- Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands
| | - Laura A Hartman
- Amsterdam UMC, VU University Medical Centre (VUmc), EMGO+, Amsterdam, the Netherlands
| | - Bert A C Molewijk
- Amsterdam UMC, VU University Medical Centre (VUmc), EMGO+, Amsterdam, the Netherlands.,Centre for Medical Ethics at the University of Oslo (UIO), Oslo, Norway
| | - Jelle L P van Gurp
- Amsterdam UMC, VU University Medical Centre (VUmc), Amsterdam, the Netherlands.,IQ Healthcare Department, Radboud University Medical Center Nijmegen, Nijmegen, the Netherlands
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Rietjens JA, Heijltjes MT, van Delden JJ, Onwuteaka-Philipsen BD, van der Heide A. The Rising Frequency of Continuous Deep Sedation in the Netherlands, a Repeated Cross-Sectional Survey in 2005, 2010, and 2015. J Am Med Dir Assoc 2019; 20:1367-1372. [DOI: 10.1016/j.jamda.2019.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 06/12/2019] [Accepted: 06/13/2019] [Indexed: 11/16/2022]
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Inguaggiato G, Metselaar S, Porz R, Widdershoven G. A pragmatist approach to clinical ethics support: overcoming the perils of ethical pluralism. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2019; 22:427-438. [PMID: 30684092 PMCID: PMC6710214 DOI: 10.1007/s11019-018-09882-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In today's pluralistic society, clinical ethics consultation cannot count on a pre-given set of rules and principles to be applied to a specific situation, because such an approach would deny the existence of different and divergent backgrounds by imposing a dogmatic and transcultural morality. Clinical ethics support (CES) needs to overcome this lack of foundations and conjugate the respect for the difference at stake with the necessity to find shared and workable solutions for ethical issues encountered in clinical practice. We argue that a pragmatist approach to CES, based on the philosophical theories of William James, John Dewey, and Charles Sanders Peirce, can help to achieve the goal of reaching practical solutions for moral problems in the context of today's clinical environment, characterized by ethical pluralism. In this article, we outline a pragmatist theoretical framework for CES. Furthermore, we will show that moral case deliberation, making use of the dilemma method, can be regarded an example of a pragmatist approach to CES.
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Affiliation(s)
- Giulia Inguaggiato
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VU University Medical Centre (VUmc), Amsterdam, The Netherlands.
| | - Suzanne Metselaar
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VU University Medical Centre (VUmc), Amsterdam, The Netherlands
| | - Rouven Porz
- Clinical Ethics Unit, Bern University Hospital 'Inselspital', Inselgruppe AG, Bern, Switzerland
| | - Guy Widdershoven
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VU University Medical Centre (VUmc), Amsterdam, The Netherlands
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Bruun H, Pedersen R, Stenager E, Mogensen CB, Huniche L. Implementing ethics reflection groups in hospitals: an action research study evaluating barriers and promotors. BMC Med Ethics 2019; 20:49. [PMID: 31311525 PMCID: PMC6636139 DOI: 10.1186/s12910-019-0387-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 07/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background An ethics reflection group (ERG) is one of a range of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the implementation process of interdisciplinary ERGs in psychiatric and general hospital departments in Denmark. To our knowledge, this is the first study of ERG implementation to include both psychiatric and general hospital departments. Methods The implementation and evaluation strategies are inspired by action research, using a qualitative approach and systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Results The implementation process was influenced by both structural factors and factors related to clinicians having different values, interests and experiences. Structural barriers and promotors in the process to implement ERG included the following sub-categories: Organizational factors, recruitment and training of ethics facilitators, the deliberation model, planning and recruitment of participants to the ERGs, the support of the ward managers and the project group. Barriers and promotors found among clinicians included the following sub-categories: Expectations and pre-understandings of ERGs, understandings of a physician’s job, challenges experienced by ethics facilitators. At the end of the study, when it was decided that the ERGs should be continued, the implementation strategies were remodeled by the participants to meet new challenges. Conclusion The study of ERG implementation identified important structural and professional barriers and promotors that are likely to be relevant to anyone wanting to implement ethics support services across various types of healthcare services.
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Affiliation(s)
- Henriette Bruun
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark.
| | - Reidar Pedersen
- Center for medical Ethics, Institute of Health and Society, University of Oslo, Kirkevejen 166, 0450, Oslo, Norway
| | - Elsebeth Stenager
- Focused Research Unit in Psychiatry, Institute of Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Christian Backer Mogensen
- Focused Research Unit in Emergency Medicine Institute for Regional Health Research, University of Southern Denmark, J.B. Winsløws Vej 19,3, 5000, Odense C, Denmark
| | - Lotte Huniche
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense M, Denmark
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de Snoo-Trimp JC, Molewijk B, Ursin G, Brinchmann BS, Widdershoven GA, de Vet HC, Svantesson M. Field-testing the Euro-MCD Instrument: Experienced outcomes of moral case deliberation. Nurs Ethics 2019; 27:390-406. [PMID: 31177947 DOI: 10.1177/0969733019849454] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Moral case deliberation is a form of clinical ethics support to help healthcare professionals in dealing with ethically difficult situations. There is a lack of evidence about what outcomes healthcare professionals experience in daily practice after moral case deliberations. The Euro-MCD Instrument was developed to measure outcomes, based on the literature, a Delphi panel, and content validity testing. To examine relevance of items and adequateness of domains, a field study is needed. AIM To describe experienced outcomes after participating in a series of moral case deliberations, both during sessions and in daily practice, and to explore correlations between items to further validate the Euro-MCD Instrument. METHODS In Sweden, the Netherlands, and Norway, healthcare institutions that planned a series of moral case deliberations were invited. Closed responses were quantitatively analyzed. The factor structure of the instrument was tested using exploratory factor analyses. ETHICAL CONSIDERATIONS The study was approved in Sweden by a review board. In Norway and the Netherlands, data services and review boards were informed about the study. RESULTS The Euro-MCD Instrument was completed by 443 and 247 healthcare professionals after four and eight moral case deliberations, respectively. They experienced especially outcomes related to a better collaboration with co-workers and outcomes about individual moral reflexivity and attitude, both during sessions and in daily practice. Outcomes were experienced to a higher extent during sessions than in daily practice. The factor structure revealed four domains of outcomes, which did not confirm the six Euro-MCD domains. CONCLUSION Field-testing the Euro-MCD Instrument showed the most frequently experienced outcomes and which outcomes correlated with each other. When revising the instrument, domains should be reconsidered, combined with theory about underlying concepts. In the future, a feasible and valid instrument will be presented to get insight into how moral case deliberation supports and improves healthcare.
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Affiliation(s)
| | - Bert Molewijk
- Amsterdam UMC, location VU Medical Center, The Netherlands; University of Oslo, Norway
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Montreuil M, Martineau JT, Racine E. Exploring Ethical Issues Related to Patient Engagement in Healthcare: Patient, Clinician and Researcher's Perspectives. JOURNAL OF BIOETHICAL INQUIRY 2019; 16:237-248. [PMID: 30741392 DOI: 10.1007/s11673-019-09904-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 01/21/2019] [Indexed: 05/13/2023]
Abstract
Patient engagement in healthcare is increasingly discussed in the literature, and initiatives engaging patients in quality improvement activities, organizational design, governance, and research are becoming more and more common and have even become mandatory for certain health institutions. Here we discuss a number of ethical challenges raised by this engagement from patients from the perspectives of research, organizational/quality improvement practices, and patient experiences, while offering preliminary recommendations as to how to address them. We identified three broad categories of ethical issues that intersect between the different types of patient engagement: (1) establishing a shared vision about goals of patient engagement and respective roles; (2) the process and method of engaging with patients; and (3) practical aspects of patient engagement. To explain these issues, we build from our personal, professional, and academic experiences, as well as traditions such as pragmatism and hermeneutics that stress the importance of participation, empowerment, and engagement. Patient engagement can be highly valuable at numerous levels, but particular attention should be paid to the process of engaging with patients and related ethical issues. Some lessons from the literature on the ethics of participatory research can be translated to organizational and quality improvement practices.
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Affiliation(s)
- Marjorie Montreuil
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal (IRCM), 110 avenue des Pins Ouest, Montréal, Québec, H2W 1R7, Canada
| | - Joé T Martineau
- Department of Management, HEC Montréal, 3000 Chemin de la Côte-Sainte-Catherine, Montréal, Québec, H3T 2A7, Canada
| | - Eric Racine
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal (IRCM), 110 avenue des Pins Ouest, Montréal, Québec, H2W 1R7, Canada.
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'You can give them wings to fly': a qualitative study on values-based leadership in health care. BMC Med Ethics 2019; 20:35. [PMID: 31133017 PMCID: PMC6537214 DOI: 10.1186/s12910-019-0374-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 05/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Within contemporary health care, many of the decisions affecting the health and well-being of patients are not being made by the clinicians or health professionals, but by those involved in health care management. Existing literature on organizational ethics provides insight into the various structures, processes and strategies - such as mission statement, ethics committees, ethical rounds … - that exist to create an organizational climate, which fosters ethical practices and decision-making It does not, however, show how health care managers experience their job as being intrinsically ethical in itself. In the present article, we investigate the way in which ethical values are present in the lived experiences and daily practice of health care management. What does it imply to take up a managing position within a health care institution and to try to do this in an ethically inspired way? METHOD We carried out a qualitative study (Grounded Theory Approach) to explore the essence of values-based leadership in health care. We interviewed 15 people with extensive experience in health care management in the fields of elderly care, hospital care and mental health care in the various regions of Flanders, Belgium. RESULTS Six predominant themes, presented as metaphors, illustrate the essence of values-based leadership in health care management. These are: (1) values-based health care management as managing a large garden, (2) as learning and using a foreign language, (3) going on a trekking with an ethical compass, (4) embodying integrity and authenticity in a credible encounter with everyone, (5) being a present and trustworthy leader during sun and storm, and (6) contributing to human flourishing by giving people wings to fly. CONCLUSIONS Notwithstanding the importance of organizing a good ethics infrastructure, values-based leadership in health care entails much more than that. It is about the co-creation of an integrated and comprehensive ethical climate of which community-model thinking and authentic leadership are essential components. As a never-ending process, the six metaphors can help leaders to take substantive proactive steps to shape a fruitful ethical climate within their organization.
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Hartman L, Widdershoven G, de Vries A, Wensing-Kruger A, Heijer MD, Steensma T, Molewijk B. Integrative Clinical Ethics Support in Gender Affirmative Care: Lessons Learned. HEC Forum 2019; 31:241-260. [PMID: 31098934 DOI: 10.1007/s10730-019-09376-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Clinical ethics support (CES) for health care professionals and patients is increasingly seen as part of good health care. However, there is a key drawback to the way CES services are currently offered. They are often performed as isolated and one-off services whose ownership and impact are unclear. This paper describes the development of an integrative approach to CES at the Center of Expertise and Care for Gender Dysphoria (CEGD) at Amsterdam University Medical Center. We specifically aimed to integrate CES into daily work processes at the CEGD. In this paper, we describe the CES services offered there in detail and elaborate on the 16 lessons we learned from the process of developing an integrative approach to CES. These learning points can inform and inspire CES professionals, who wish to bring about greater integration of CES services into clinical practice.
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Affiliation(s)
- Laura Hartman
- Department of Medical Humanities, Amsterdam UMC, Amsterdam, The Netherlands.
| | - Guy Widdershoven
- Department of Medical Humanities, Amsterdam UMC, Amsterdam, The Netherlands
| | - Annelou de Vries
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Amsterdam, The Netherlands
| | - Annelijn Wensing-Kruger
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Medical Psychology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Martin den Heijer
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Amsterdam, The Netherlands
| | - Thomas Steensma
- Centre of Expertise on Gender Dysphoria, Amsterdam UMC, Amsterdam, The Netherlands.,Department of Medical Psychology, Amsterdam UMC, Amsterdam, The Netherlands
| | - Bert Molewijk
- Department of Medical Humanities, Amsterdam UMC, Amsterdam, The Netherlands.,Faculty of Medicine, Centre for Medical Ethics, Institute of Health and Society, University of Oslo, Oslo, Norway
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Hartman LA, Metselaar S, Molewijk AC, Edelbroek HM, Widdershoven GAM. Developing an ethics support tool for dealing with dilemmas around client autonomy based on moral case deliberations. BMC Med Ethics 2018; 19:97. [PMID: 30577790 PMCID: PMC6303905 DOI: 10.1186/s12910-018-0335-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 12/03/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Moral Case Deliberations (MCDs) are reflective dialogues with a group of participants on their own moral dilemmas. Although MCD is successful as clinical ethics support (CES), it also has limitations. 1. Lessons learned from individual MCDs are not shared in order to be used in other contexts 2. Moral learning stays limited to the participants of the MCD; 3. MCD requires quite some organisational effort, 4. MCD deals with one individual concrete case. It does not address other, similar cases (it is case based). These limitations warrant research into complementary ways of providing CES to healthcare professionals. Our research objective was therefore to develop a low threshold CES tool based on a series of MCDs on autonomy in long-term care. METHODS We used a qualitative research design in which we analyzed the process and content of a series of MCDs, combined with reflections on the theoretical background of MCD. In total 28 MCDs (10 transcripts and 18 summary reports) were analyzed by means of a thematic content analysis. In various rounds of development, the results of the analysis were combined with theoretical reflections on CES. Consequently, the tool was evaluated in three focus groups and adjusted. RESULTS The CES tool, called 'moral compass', guides the users through a series of six subsequent questions in order to methodically reflect on their concrete moral dilemma, in the form of a booklet of 23 pages. It combines a methodical element that encourages and structures a reflection process with a substantive element, including norms, values, options, strategies, and insights regarding dealing with client autonomy. CONCLUSION By using data from a series of MCDs, combined with theoretical reflections on MCD, ethics support and moral learning, we developed a thematic, low-threshold CES tool that supports healthcare professionals in daily practice in dealing with moral questions regarding client autonomy. It integrates examples and insights from earlier MCDs on the same topic. The moral compass is not a replacement of, but can be used complementary to MCD. The feasibility and impact of the moral compass need to be investigated in an evaluative follow-up study. The methodology presented in this paper may be used to develop moral compasses on different topics in various healthcare organizations.
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Affiliation(s)
- L. A. Hartman
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
| | - S. Metselaar
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
| | - A. C. Molewijk
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
- Centre for Medical Ethics, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - H. M. Edelbroek
- Institute for Interdisciplinary Studies, University of Amsterdam, Amsterdam, The Netherlands
| | - G. A. M. Widdershoven
- Department of Medical Humanities, VU University Medical Centre, APH, Amsterdam, The Netherlands
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Heidenreich K, Bremer A, Materstvedt LJ, Tidefelt U, Svantesson M. Relational autonomy in the care of the vulnerable: health care professionals' reasoning in Moral Case Deliberation (MCD). MEDICINE, HEALTH CARE, AND PHILOSOPHY 2018; 21:467-477. [PMID: 29243015 PMCID: PMC6267250 DOI: 10.1007/s11019-017-9818-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
In Moral Case Deliberation (MCD), healthcare professionals discuss ethically difficult patient situations in their daily practice. There is a lack of knowledge regarding the content of MCD and there is a need to shed light on this ethical reflection in the midst of clinical practice. Thus, the aim of the study was to describe the content of healthcare professionals' moral reasoning during MCD. The design was qualitative and descriptive, and data consisted of 22 audio-recorded inter-professional MCDs, analysed with content analysis. The moral reasoning centred on how to strike the balance between personal convictions about what constitutes good care, and the perceived dissonant care preferences held by the patient. The healthcare professionals deliberated about good care in relation to demands considered to be unrealistic, justifications for influencing the patient, the incapacitated patient's nebulous interests, and coping with the conflict between using coercion to achieve good while protecting human dignity. Furthermore, as a basis for the reasoning, the healthcare professionals reflected on how to establish a responsible relationship with the vulnerable person. This comprised acknowledging the patient as a susceptible human being, protecting dignity and integrity, defining their own moral responsibility, and having patience to give the patient and family time to come to terms with illness and declining health. The profound struggle to respect the patient's autonomy in clinical practice can be understood through the concept of relational autonomy, to try to secure both patients' influence and at the same time take responsibility for their needs as vulnerable humans.
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Affiliation(s)
- Kaja Heidenreich
- Faculty of Health and Medicine, University Health Care Research Center, Örebro University, Box 1613, 701 16, Örebro, Sweden.
| | - Anders Bremer
- Department of Health and Caring Sciences, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
- PreHospen - Centre for Prehospital Research, University of Borås, Borås, Sweden
| | - Lars Johan Materstvedt
- Department of Philosophy and Religious Studies, Faculty of Humanities, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Glasgow End of Life Studies Group, School of Interdisciplinary Studies, University of Glasgow, Dumfries Campus, Scotland, UK
| | - Ulf Tidefelt
- Faculty of Health and Medicine, University Health Care Research Center, Örebro University, Box 1613, 701 16, Örebro, Sweden
| | - Mia Svantesson
- Faculty of Health and Medicine, University Health Care Research Center, Örebro University, Box 1613, 701 16, Örebro, Sweden
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Antonsen Y, Normann AK, Nilsen HR, Magelssen M. Systematisk etikkarbeid krever lederforankring. TIDSSKRIFT FOR OMSORGSFORSKNING 2018. [DOI: 10.18261/issn.2387-5984-2018-01-06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Tan DYB, Ter Meulen BC, Molewijk A, Widdershoven G. Moral case deliberation. Pract Neurol 2017; 18:181-186. [PMID: 29263135 DOI: 10.1136/practneurol-2017-001740] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2017] [Indexed: 11/03/2022]
Abstract
Ethical dilemmas in general are characterised by a choice between two mutually excluding options neither of which is satisfactory, because there always will be a form of moral damage. Within the context of medicine several ethics support services have been developed to support healthcare professionals in dealing with ethical dilemmas, including moral case deliberation. In this article, we describe how moral case deliberation works in daily practice, illustrated with a case example from the neurology ward. The article is meant as an introduction to moral case deliberation according to the dilemma method. We show its relevance to the clinic and the context needed to put it into practice.
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Affiliation(s)
- Daniel Y B Tan
- Department of Neurology, OLVG Locatie West, Amsterdam, The Netherlands
| | - Bastiaan C Ter Meulen
- Department of Neurology, OLVG Locatie West, Amsterdam, The Netherlands.,Department of Neurology, Zaans Medical Center, Zaandam, The Netherlands
| | - Albert Molewijk
- Department of Medical Humanities, VU University Medical Center (VUmc), Amsterdam, The Netherlands.,Center for Medical Ethics, Faculty of Medicine, Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Guy Widdershoven
- Department of Medical Humanities, VU University Medical Center (VUmc), Amsterdam, The Netherlands
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Rasoal D, Skovdahl K, Gifford M, Kihlgren A. Clinical Ethics Support for Healthcare Personnel: An Integrative Literature Review. HEC Forum 2017; 29:313-346. [PMID: 28600658 PMCID: PMC5688194 DOI: 10.1007/s10730-017-9325-4] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This study describes which clinical ethics approaches are available to support healthcare personnel in clinical practice in terms of their construction, functions and goals. Healthcare personnel frequently face ethically difficult situations in the course of their work and these issues cover a wide range of areas from prenatal care to end-of-life care. Although various forms of clinical ethics support have been developed, to our knowledge there is a lack of review studies describing which ethics support approaches are available, how they are constructed and their goals in supporting healthcare personnel in clinical practice. This study engages in an integrative literature review. We searched for peer-reviewed academic articles written in English between 2000 and 2016 using specific Mesh terms and manual keywords in CINAHL, MEDLINE and Psych INFO databases. In total, 54 articles worldwide described clinical ethics support approaches that include clinical ethics consultation, clinical ethics committees, moral case deliberation, ethics rounds, ethics discussion groups, and ethics reflection groups. Clinical ethics consultation and clinical ethics committees have various roles and functions in different countries. They can provide healthcare personnel with advice and recommendations regarding the best course of action. Moral case deliberation, ethics rounds, ethics discussion groups and ethics reflection groups support the idea that group reflection increases insight into ethical issues. Clinical ethics support in the form of a "bottom-up" perspective might give healthcare personnel opportunities to think and reflect more than a "top-down" perspective. A "bottom-up" approach leaves the healthcare personnel with the moral responsibility for their choice of action in clinical practice, while a "top-down" approach risks removing such moral responsibility.
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Affiliation(s)
- Dara Rasoal
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden.
| | - Kirsti Skovdahl
- Department of Nursing and Health Sciences, University College in Southeast Norway, Drammen, Norway
| | - Mervyn Gifford
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, Sweden
| | - Annica Kihlgren
- School of Health and Medical Sciences, Örebro University, Fakultetsgatan 1, SE - 701 82, Örebro, 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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Svantesson M, Silén M, James I. It’s not all about moral reasoning: Understanding the content of Moral Case Deliberation. Nurs Ethics 2017; 25:212-229. [DOI: 10.1177/0969733017700235] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Moral Case Deliberation is one form of clinical ethics support described as a facilitator-led collective moral reasoning by healthcare professionals on a concrete moral question connected to their practice. Evaluation research is needed, but, as human interaction is difficult to standardise, there is a need to capture the content beyond moral reasoning. This allows for a better understanding of Moral Case Deliberation, which may contribute to further development of valid outcome criteria and stimulate the normative discussion of what Moral Case Deliberation should contain. Objective: To explore and compare the content beyond moral reasoning in the dialogue in Moral Case Deliberation at Swedish workplaces. Methods: A mixed-methods approach was applied for analysing audio-recordings of 70 periodic Moral Case Deliberation meetings at 10 Swedish workplaces. Moral Case Deliberation facilitators and various healthcare professions participated, with registered nurses comprising the majority. Ethical considerations: No objection to the study was made by an Ethical Review Board. After oral and written information was provided, consent to be recorded was assumed by virtue of participation. Findings: Other than ‘moral reasoning’ (median (md): 45% of the spoken time), the Moral Case Deliberations consisted of ‘reflections on the psychosocial work environment’ to a varying extent (md: 29%). Additional content comprised ‘assumptions about the patient’s psychosocial situation’ (md: 6%), ‘facts about the patient’s situation’ (md: 5%), ‘concrete problem-solving’ (md: 6%) and ‘process’ (md: 3%). Conclusion: The findings suggest that a restorative function of staff’s wellbeing in Moral Case Deliberation is needed, as this might contribute to good patient care. This supports outcome criteria of improved emotional support, which may include relief of moral distress. However, facilitators need a strategy for how to proceed from the participants’ own emotional needs and to develop the use of their emotional knowing to focus on the ethically difficult patient situation.
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Affiliation(s)
| | - Marit Silén
- University of Gävle, Sweden; Uppsala University, Sweden
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Palliative sedation challenging the professional competency of health care providers and staff: a qualitative focus group and personal written narrative study. BMC Palliat Care 2017; 16:25. [PMID: 28399846 PMCID: PMC5387333 DOI: 10.1186/s12904-017-0198-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 04/04/2017] [Indexed: 11/18/2022] Open
Abstract
Background Despite recent advances in palliative medicine, sedating a terminally ill patient is regarded as an indispensable treatment to manage unbearable suffering. With the prospect of widespread use of palliative sedation, the feelings and representations of health care providers and staff (carers) regarding sedation must be carefully explored if we are to gain a better understanding of its impact and potential pitfalls. The objective of the study was to provide a comprehensive description of the opinions of carers about the use of sedation practices in palliative care units (PCU), which have become a focus of public attention following changes in legislation. Methods Data were collected using a qualitative study involving multi-professional focus groups with health care providers and staff as well as personal narratives written by physicians and paramedical staff. A total of 35 medical and paramedical providers volunteered to participate in focus group discussions in three Palliative Care Units in two French hospitals and to write personal narratives. Results Health care provider and staff opinions had to do with their professional stance and competencies when using midazolam and practicing sedation in palliative care. They expressed uncertainty regarding three aspects of the comprehensive care: biomedical rigour of diagnosis and therapeutics, quality of the patient/provider relationship and care to be provided. Focusing on the sedative effect of midazolam and continuous sedation until death, the interviewed health care providers examined the basics of their professional competency as well as the key role played by the health care team in terms of providing support and minimizing workplace suffering. Nurses were subject to the greatest misgivings about their work when they were called upon to sedate patients. Conclusions The uncertainty experienced by the carers with regard to the medical, psychosocial and ethical justification for sedation is a source of psychological burden and moral distress, and it has proved to be a major source of suffering in the workplace. Lastly, the study shows the uncertainty can have the positive effect of prompting the care team to devise ways to deal with it.
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Bartholdson C, Molewijk B, Lützén K, Blomgren K, Pergert P. Ethics case reflection sessions: Enablers and barriers. Nurs Ethics 2017. [PMID: 29529973 DOI: 10.1177/0969733017693471] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In previous research on ethics case reflection (ECR) sessions about specific cases, healthcare professionals in childhood cancer care were clarifying their perspectives on the ethical issue to resolve their main concern of consolidating care. When perspectives were clarified, consequences in the team included 'increased understanding', 'group strengthening' and 'decision grounding'. Additional analysis of the data was needed on conditions that could contribute to the quality of ECR sessions. OBJECTIVE The aim of this study was to explore conditions for clarifying perspectives during ECR sessions. RESEARCH DESIGN Data were collected from observations and interviews and the results emerged from an inductive analysis using grounded theory. Participants and research context: Six observations during ECR sessions and 10 interviews were performed with healthcare professionals working in childhood cancer care and advanced paediatric homecare. Ethical considerations: The study was approved by a regional ethical review board. Participants were informed about their voluntary involvement and that they could withdraw their participation without explaining why. FINDINGS Two categories emerged: organizational enablers and barriers and team-related enablers and barriers. Organizational enablers and barriers included the following sub-categories: the timing of the ECR session, the structure during the ECR session and the climate during the ECR session. Sub-categories to team-related enablers and barriers were identified as space for inter-professional perspectives, varying levels of ethical skills and space for the patient's and the family's perspectives. DISCUSSION Space for inter-professional perspectives included the dominance of a particular perspective that can result from hierarchical positions. The medical perspective is relevant for understanding the child's situation but should not dominate the ethical reflection. CONCLUSION Conditions for ECR sessions have been explored and the new knowledge can be used when training facilitators as well as for those who organize/implement ECR sessions. Awareness of space for different perspectives, including the possible medical advantage over the nursing perspective, could reduce the somewhat unilateral attention and contribute to an inter-professionally shared reflection.
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Affiliation(s)
- Cecilia Bartholdson
- Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden.,Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Bert Molewijk
- VU University Medical Center Amsterdam, The Netherlands; University of Oslo, Norway.,Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Kim Lützén
- Karolinska Institutet, Sweden.,Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Klas Blomgren
- Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
| | - Pernilla Pergert
- Karolinska Institutet, Sweden; Karolinska University Hospital, Sweden
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Widdershoven G, Metselaar S, Molewijk B. Ethical Theory as Part of Clinical Ethics Support Practice. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2016; 16:34-36. [PMID: 27471936 DOI: 10.1080/15265161.2016.1196260] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
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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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Rasoal D, Kihlgren A, James I, Svantesson M. What healthcare teams find ethically difficult. Nurs Ethics 2016; 23:825-837. [DOI: 10.1177/0969733015583928] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Ethically difficult situations are frequently encountered by healthcare professionals. Moral case deliberation is one form of clinical ethics support, which has the goal to support staff to manage ethical difficulties. However, little is known which difficult situations healthcare teams need to discuss. Aim: To explore which kinds of ethically difficult situations interprofessional healthcare teams raise during moral case deliberation. Research design: A series of 70 moral case deliberation sessions were audio-recorded in 10 Swedish workplaces. A descriptive, qualitative approach was applied, using thematic content analysis. Ethical considerations: An advisory statement specifying no objections to the study was provided from an Ethical Review Board, and consent to be recorded was assumed by virtue of participation in the moral case deliberation. Findings: Three themes emerged: powerlessness over managing difficult interactions with patients and next-of-kin, unease over unsafe and unequal care, and uncertainty over who should have power over care decisions. The powerlessness comprised feelings of insufficiency, difficulties to respond or manage patient’s/next-of-kin’s emotional needs or emotional outbursts and discouragement over motivating patients not taking responsibility for themselves. They could be uncertain over the patient’s autonomy, who should have power over life and death, disclosing the truth or how much power next-of-kin should have. Discussion: The findings suggest that the nature of the ethically difficult situations brought to moral case deliberations contained more relational-oriented ethics than principle-based ethics, were permeated by emotions and the uncertainties were pervaded by power aspects between stakeholders. Conclusion: MCD can be useful in understanding the connection between ethical issues and emotions from a team perspective.
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Affiliation(s)
| | | | | | - Mia Svantesson
- Faculty of Health and Medicine, Örebro University, Sweden
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Stolper M, Molewijk B, Widdershoven G. Bioethics education in clinical settings: theory and practice of the dilemma method of moral case deliberation. BMC Med Ethics 2016; 17:45. [PMID: 27448597 PMCID: PMC4957934 DOI: 10.1186/s12910-016-0125-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 06/17/2016] [Indexed: 11/29/2022] Open
Abstract
Background Moral Case Deliberation is a specific form of bioethics education fostering professionals’ moral competence in order to deal with their moral questions. So far, few studies focus in detail on Moral Case Deliberation methodologies and their didactic principles. The dilemma method is a structured and frequently used method in Moral Case Deliberation that stimulates methodological reflection and reasoning through a systematic dialogue on an ethical issue experienced in practice. Methods In this paper we present a case-study of a Moral Case Deliberation with the dilemma method in a health care institution for people with an intellectual disability, describing the theoretical background and the practical application of the dilemma method. The dilemma method focuses on moral experiences of participants concerning a concrete dilemma in practice. By an in-depth description of each of the steps of the deliberation process, we elucidate the educational value and didactics of this specific method. Results The didactics and methodical steps of the dilemma method both supported and structured the dialogical reflection process of the participants. The process shows that the participants learned to recognize the moral dimension of the issue at stake and were able to distinguish various perspectives and reasons in a systematic manner. The facilitator played an important role in the learning process of the participants, by assisting them in focusing on and exploring moral aspects of the case. Discussion The reflection and learning process, experienced by the participants, shows competency-based characteristics. The role of the facilitator is that of a Socratic teacher with specific knowledge and skills, fostering reflection, inquiry and dialogue. Conclusion The specific didactics of the dilemma method is well suited for teaching bioethics in clinical settings. The dilemma method follows an inductive learning approach through a dialogical moral inquiry in which participants develop not only knowledge but also skills, attitude and character. The role of a trained facilitator and a specific view on teaching and practicing ethics are essential when using the dilemma method in teaching health care professionals how to reflect on their own moral issues in practice.
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Affiliation(s)
- Margreet Stolper
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VU University medical centre (VUmc), De Boelenlaan 1089a, 1081, HV, Amsterdam, The Netherlands.
| | - Bert Molewijk
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VU University medical centre (VUmc), De Boelenlaan 1089a, 1081, HV, Amsterdam, The Netherlands.,Centre of Medical Ethics, University of Oslo, Oslo, Norway
| | - Guy Widdershoven
- Department of Medical Humanities, EMGO+ Institute for Health and Care Research, VU University medical centre (VUmc), De Boelenlaan 1089a, 1081, HV, Amsterdam, The Netherlands
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Molewijk B, Engerdahl IS, Pedersen R. Two years of moral case deliberations on the use of coercion in mental health care: Which ethical challenges are being discussed by health care professionals? ACTA ACUST UNITED AC 2016. [DOI: 10.1177/1477750915622034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background Seven wards from three Norwegian mental health care institutions participated in a study in which regular ethics reflection groups focusing on coercion had been implemented and evaluated (2011–2015). This article presents (1) a thematic overview of the ethical challenges identified based on a systematic qualitative analyses of 161 ethics reflection groups and (2) some general observations on these ethical challenges. Results The ethical challenges are divided into four main thematic categories: (1) formal coercion, (2) informal coercion, (3) uncertainty related to the Norwegian legislation on coercion and (4) professional role and identity. Some ethical challenges did not fit into these categories. Only 36% of the ethical challenges were related to the use of formal coercion or the interpretation of the health law. Conclusion Even within coercion regulated by law, weighing different moral values remains important to reflect upon the appropriateness of the possible use of coercion.
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Affiliation(s)
- Bert Molewijk
- Institute of Health and Society, Center for Medical Ethics, University of Oslo, Norway
- Department of Medical Humanities, VU University Medical Centre (VUmc), EMGO+, the Netherlands
| | | | - Reidar Pedersen
- Institute of Health and Society, Center for Medical Ethics, University of Oslo, Norway
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Seekles W, Widdershoven G, Robben P, van Dalfsen G, Molewijk B. Evaluation of moral case deliberation at the Dutch Health Care Inspectorate: a pilot study. BMC Med Ethics 2016; 17:31. [PMID: 27209161 PMCID: PMC4875757 DOI: 10.1186/s12910-016-0114-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 05/11/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Moral case deliberation (MCD) as a form of clinical ethics support is usually implemented in health care institutions and educational programs. While there is no previous research on the use of clinical ethics support on the level of health care regulation, employees of regulatory bodies are regularly confronted with moral challenges. This pilot study describes and evaluates the use of MCD at the Dutch Health Care Inspectorate (IGZ). The objective of this pilot study is to investigate: 1) the current way of dealing with moral issues at the IGZ; 2) experience with and evaluation of MCD as clinical ethics support, and 3) future preferences and (perceived) needs regarding clinical ethics support for dealing with moral questions at the IGZ. METHODS We performed an explorative pilot study. The research questions were assessed by means of: 1) interviews with MCD participants during four focus groups; and 2) interviews with six key stakeholders at the IGZ. De qualitative data is illustrated by data from questionnaires on MCD outcomes, perspective taking and MCD evaluation. RESULTS Professionals do not always recognize moral issues. Employees report a need for regular and structured moral support in health care regulation. The MCD meetings are evaluated positively. The most important outcomes of MCD are feeling secure and learning from others. Additional support is needed to successfully implement MCD at the Inspectorate. CONCLUSION We conclude that the respondents perceive moral case deliberation as a useful form of clinical ethics support for dealing with moral questions and issues in health care regulation.
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Affiliation(s)
- Wike Seekles
- Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands. .,University of Humanistic Studies, Utrecht, The Netherlands.
| | - Guy Widdershoven
- Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands
| | - Paul Robben
- The Health Care Inspectorate (IGZ), Utrecht, The Netherlands.,Institute of Health Policy and Management (iBMG), Erasmus University Rotterdam, Rotterdam, The Netherlands
| | | | - Bert Molewijk
- Medical Humanities, VU University Medical Centre, Amsterdam, The Netherlands.,Centre of Medical Ethics, HELSAM, University of Oslo, Oslo, Norway
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Ethics Consultation Services: The Scenario. SPRINGERBRIEFS IN APPLIED SCIENCES AND TECHNOLOGY 2016. [DOI: 10.1007/978-3-319-27690-8_1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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